
aft 




■ ' 








Qass. 
Book 



COPYRIGHT DEPOSIT 



A TREATISE 



THE SCIENCE AND PRACTICE 



OF 



MIDWIFEBY 



BY 

W. S. PLAYFAIR, M.D., LL.D., F.R.C.P., 

PHYSICI AX- ACCOUCHEUR TO H.I. AND R.H. THE DUCHESS OF SAXE-COBURG AND GOTHA (DUCHESS OF 

EDINBURGH ; EMERITUS PROFESSOR OF OBSTETRIC MEDICINE IN KING'S COLLEGE; 

CONSULTING PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO 

KING'S COLLEGE HOSPITAL, THE GENERAL LYING-IN HOSPITAL, THE 

EVELINA HOSPITAL FOR CHILDREN. ETC. J LATE PRESIDENT OF 

THE OBSTETRICAL SOCIETY" OF LONDON ; EXAMINER IN 

MIDWIFERY TO THE UNIVERSITIES OF CAMBRIDGE 

AND LONDON, AND TO THE ROYAL 

COLLEGE OF PHYSICIANS. 



SEVENTH AMERICAN FROM THE NINTH ENGLISH EDITION, 



WITH 7 PLATES A 



N 1f 



07 ILLUSTRATIONS. 




t- <?£ 



LEA BROTHERS &'C6/ ^ 

PHILADELPHIA AND NEW YORK, 

1898. 






1 4389 

Entered according to the Act of Congress, in the year 1898, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 




TWO COPIES RECEIVED. 






189,). 



£ 




PREFACE TO THE NINTH ENGLISH EDITION 



In the last edition of this work, published in 1893, many changes 
were made to enable it to keep pace with the rapid advance of Obstet- 
ric Science. The exhaustion of the large edition then printed calls 
for a new one. dj 

Twenty-two years have now elapsed since the first edition was 
published. The author has endeavored to celebrate the fact of his 
♦vork having attained its majority by a very thorough revision of 
text, many parts of which have been completely re- written. 
wo new plates and seventeen woodcuts have been added, while 
jveral illustrations which seemed obsolete or unsatisfactory have 
jeen suppressed. He thus hopes to secure for his book the same 
favorable reception in the future that has been extended to it in the 
past, for which he is very grateful. He has specially to acknowl- 
edge his obligation to Dr. T. "W. Eden. That gentleman's well- 
known work in connection with Placental Anatomy and cognate 
subjects tempted the author to ask him to be good enough to revise 
the chapter on " Conception and Generation." This he has done so 
thoroughly as practically to amount to re-writing of the chapter, 
much, the author feels sure, to the benefit of his readers. His 
thanks are also due to his colleague, Prof. Crookshank, for permis- 
sion to use several illustrations from his beautiful work on Bacteri- 
ology, and to his cousin, Dr. Hugh Playfair, for much valuable 
assistance in revision of the proofs. 

38 Grosvenor St . , W. 
May, 1898. 



(Hi) 



AUTHOR'S PREFACE TO THE FIRST EDITION. 



Those who have studied the progress of Midwifery know that 
there is no department of medicine in which more has been done of 
late years, and none in which modern views of practice differ more 
widely from those prevalent only a short time ago. The Author's 
object has been to place in the hands of his readers an epitome of 
the science and practice of midwifery which embodies all recent 
advances. He is aware that on certain important points he has 
recommended practice which not long ago would have been consid- 
ered heterodox in the extreme, and which, even now, will not meet 
with general approval, He has, however, the satisfaction of know- 
ing that he has only done so after very deliberate reflection, and 
with the profound conviction that such changes are right, and that 
they will stand the test of experience. He has endeavored to dwell 
especially on the practical part of the subject, so as to make the work 
a useful guide in this most anxious and most responsible branch of 
the profession. It is admitted by all, that emergencies and difficul- 
ties arise more often in this than in any other branch of practice ; 
and there is no part of the practitioner's work which requires more 
thorough knowledge or greater experience. It is, moreover, a lamen- 
table fact that students generally leave their schools more ignorant of 
obstetrics than of any other subject. So long as the absurd regula- 
tions exist which oblige the lecturer on midwifery to attempt the 
impossible task of teaching obstetrics in a short three months' course 
— an absurdity which has over and over again been pointed out — 
such must of necessity be the case. This must be the Author's 
excuse for dwelling on many topics at greater length than some will 
doubtless think their importance merits, since he desires to place in 
the hands of his students a work which may in some measure supply 
the inevitable defects of his lectures. 

( v) 



vi author's preface to first edition. 

Man}' of the illustrations are copied from previous authors, while 
some are original. The following quotation from the preface to 
Tyler Smith's Manual of Obstetrics will explain why the source 
of the copied woodcuts has not been in each instance acknowledged : 
"When I began to publish, I determined to give the authority for 
every woodcut copied from other works. I soon found, however, 
that obstetric authors of all countries, from the time of Mauriceau 
downward, had copied each other so freely without acknowledgment 
as to render it difficult or impossible to trace the originals." 

The Author has to express his acknowledgments to many friends 
for their kind assistance by the loan of illustrations and otherwise, 
and more especially to his colleague, Dr. Hayes, for his valuable 
aid in passing the work through the press. 

31 George Street, Hanover Square. 
March, 1876. 



CONTENTS. 



PART I. 



ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 
IN PARTURITION. 



CHAPTER I. 

ANATOMY OF THE PELVIS. 

PAGE 

Its importance — Formation of pelvis — The os innominatum ; its three divisions 
—Separation between the true and false pelvis — The sacrum and coccyx — 
Mechanical relations of the sacrum — Pelvic articulations and ligaments — 
Movements of the pelvic joints — The pelvis as a whole — Differences in the 
two sexes — Measurements of the pelvis — Its diameters, planes, and axes — 
Development of the pelvis — Pelvis in different races — Soft parts in connec- 
tion with the pelvis . 33 

CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

Division according to function : 1. External or copulative ; 2. Internal or for- 
mative organs — Mons veneris — Labia majora and minora — The clitoris — 
The vestibule and orifice of urethra — Passing of the female catheter — Orifice 
of vagina — The hymen — Carunculse myrtiformes — The glands of the vulva 
— The perineum — The vagina — Bacteriology of the genital tract — The 
uterus: its position and anatomy — The ligaments of the uterus — The par- 
ovarium — The Fallopian tubes — The ovaries — The Graafian follicles and 
the ova — The mammary glands . . . . . . . ■ . .49 

CHAPTER III. 

OVULATION AND MENSTRUATION. 

Functions of the ovary — Changes in the Graafian follicle : 1. Maturation ; 2. 
Escape of the ovum — Formation of the corpus luteum — Quality and source 
of the menstrual blood — Theory of menstruation— Purpose of the menstrual 
loss — Vicarious menstruation —Cessation of menstruation .... 83 

(vii) 



Vlll CONTENTS. 

PAKT II. 

PREGNANCY. 



CHAPTER I. 

CONCEPTION AND GENERATION. 

PAGE 

Impregnation, fertilization, and development — The semen— Transit of sperma- 
tozoa — The ovum, penetration of spermatozoon, segmentation of the ovum 
— The muriform body — The blastoderm — The medullary groove— The 
amnion and the chorion — The allantois — Changes in the endometrium — 
The decidua — The chorion villi — Nutrition of the early ovum — The early 
placenta — Establishment of maternal circulation — Functions of the placenta 
— The chorion lseve — The amnion — The umbilical cord — The placenta at 
term 97 

CHAPTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE FOETUS. 

Appearance of the foetus at various stages of development — Anatomy of the foetal 
head — The sutures and fontanelles — Influence of sex and race on the foetal 
head — Position of the foetus in utero — Functions of the foetus — The foetal 
circulation . 124 

CHAPTER III. 

PREGNANCY. 

Changes in the form and dimensions of the uterus — Changes in the cervix — 
Changes in the texture of the uterine tissues, the peritoneal, muscular, 
and mucous coats — General modifications in the body produced by preg- 
nancy ... 139 

CHAPTER IV. 

SIGNS AND SYMPTOMS OF PREGNANCY. 

Signs of a fruitful conception — Cessation of menstruation — Sympathetic dis- 
turbances—Morning sickness, etc. — Mammary changes — Enlargement of 
the abdomen — Quickening — Intermittent uterine contractions — Vaginal 
signs of pregnancy — Ballottement, etc. — Auscultatory signs of pregnancy 
Foetal pulsations — Uterine souffle, etc 151 

CHAPTER V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY— SPURIOUS PREGNANCY — THE 
DURATION OF PREGNANCY — SIGNS OF RECENT PREGNANCY. 

Adipose enlargement of the abdomen — Distention of the uterus by retained 
menses, etc. — Congestive enlargement of the uterus — Ascites — Uterine and 
ovarian tumors— Spurious pregnancy ; its causes, symptoms, and diagnosis 
—The duration of pregnancy— Sources of fallacy— Methods of predicting 
date of delivery — Protraction of pregnancy— Signs of recent delivery 165 






CONTENTS. IX 

CHAPTEE VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER-FCETATION, 

EXTRA-UTERINE FOETATION, AND MISSED LABOR. 

PAGE 

Plural births ; their frequency, relative frequency in different countries, causes, 
etc. — Super-foetation and super-fecundation — Nature — Explanation — Ob- 
jections to admission of such cases — Their possibility admitted — Extra- 
uterine pregnancy— Classification — Causes— Tubal pregnancies — Changes 
in the Fallopian tubes — Condition of uterus — Progress and termination — 
Diagnosis — Treatment — Abdominal pregnancy ; description, diagnosis, 
treatment — Missed labor ; its symptoms, causes and treatment . . . 174 

CHAPTER VII. 

DISEASES OF PREGNANCY. 

Some only sympathetic, others mechanical or complex in their origin — 
Derangement of the digestive organs; excessive nausea and vomiting, 
diarrhoea, constipation, hemorrhoids, ptyalism, dyspnoea, etc. — Palpitation 
— Syncope — Anaemia and chlorosis — Albuminuria 203 

CHAPTER VIII. 

diseases of pregnancy (continued). 

Disorders of the nervous system ; insomnia, headaches, and neuralgia, paralysis 
— Chorea ; tetanus and tetany ; disorders of the urinary organs ; retention 
of urine ; irritability of the bladder, incontinence of urine, phosphatic 
deposits — Leucorrhoea — Effects of pressure — Laceration of veins — Displace- 
ments of the gravid uterus ; prolapse, anteversion, retroversion — Diseases 
co-existing with pregnancy ; eruptive fevers, smallpox, measles, scarlet 
fever, continued fever, phthisis, cardiac disease, syphilis, icterus, mollitis 
ossium carcinoma — Pregnancy complicated with ovarian and fibroid tumors 216 

CHAPTER IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the decidua — Hydrorrhoea gravidarum — Pathology of the chorion ; 
vesicular degeneration, myxoma fibrosum — Deciduoma malignum — Path- 
ology of the placenta ; blood extravasations, fatty degeneration, etc. — 
Pathology of the umbilical cord — Pathology of the amnion, hydramnios, 
deficiency of liquor amnii, etc. — Pathology of the foetus; blood diseases 
transmitted through the mother, smallpox, measles and scarlet fever, inter- 
mittent fevers, lead poisoning, syphilis— Inflammatory diseases — Dropsies 
— Tumors — Wounds and injuries of the foetus — Intra-uterine amputations 
— Maternal impressions — Death of the foetus 234 

CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Importance and frequency — Definition and classification — Frequency — Recur- 
rence — Causes — Causes referable to foetus — Changes in a dead ovum retained 
in utero — Extravasations of blood— Moles, etc. — Causes depending on ma- 
ternal state, syphilis — Causes acting through nervous system, physical 



CONTENTS 



PAGE 



causes, etc. — Causes depending on morbid states of uterus— Symptoms — 
Preventive treatment — Prophylactic treatment — Treatment when abortion 
is inevitable— Detention in utero of a blighted ovum — Spurious abortion — 
After-treatment 255 



PART III. 

LABOE. 



CHAPTER I. 

THE PHENOMENA OF LABOR. 

Causes of labor — Mode in which the expulsion of the child is effected — The 
uterine contraction — Mode in which the dilatation of the cervix is effected 
— Rupture of the membranes — Character and source of pains during labor 
— Effect of pains on mother and foetus — Division of labor into stages — 
Preparatory stage — False pains — First stage — Second stage — Third stage — 
Mode in which the placenta is expelled — Duration of labor . . . 268 

CHAPTER II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of subject — Frequency of head presentations — The different posi- 
tions of the head — First position — Division of mechanical movements into 
stages— Flexion — Descent and levelling movement — Rotation — Extension 
— External rotation — Second position — Third position — Fourth position — 
Caput succedaneum — Alteration in shape of head from moulding . . 282 

CHAPTER III. 

MANAGEMENT OF NATURAL LABOR. 

Preparatory treatment — Dress of patient during pregnancy — The obstetric bag 
— Duties on first visiting patient — Antiseptic precautions— False pains — 
Their character and treatment — Vaginal examination — The position of 
patient — Artificial rupture of membranes — Treatment of propulsive stage 
— Relaxation of the perineum — Treatment of lacerations — Expulsion of 
child — Promotion of uterine contraction — Ligature of the cord — Manage- 
ment of the third stage of labor — Application of the binder — After-treat- 
ment 295 

CHAPTER IV. 

ANAESTHESIA IN LABOR. 

Agents employed — Chloral : its object and mode of administration — Ether, 
chloroform, A.C.E. mixture; their use, objections to, and mode of ad- 
ministration 312 



CONTENTS. XI 

CHAPTER V. 

PELVIC PRESENTATIONS. 

PAGE 

Frequency — Causes — Prognosis to mother and child — Diagnosis by abdominal 
palpation and by vaginal examination — Differential diagnosis of breech, 
knee, and feet — Mechanism — Treatment — Management of impacted breech 
presentations ............ 315 

CHAPTER VI. 

PRESENTATIONS OF THE FACE. 

Erroneous views formerly held on the subject— Frequency — Mode of production 
— Diagnosis — Mechanism — Four positions of the face — Description of de- 
livery in first face position — Mento-posterior position in which rotation 
does not take place — Prognosis — Treatment— Brow presentation . . 327 

CHAPTER VH. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

Causes of face to pubes delivery — Mode of treatment — Upward pressure on 
forehead — Downward traction on occiput — Manual rectification of — Use of 
forceps — Peculiarities of forceps delivery 337 

CHAPTER VIII. 

PRESENTATIONS OF SHOULDER, ARM, OR TRUNK — COMPLEX PRESENTATIONS 
— PROLAPSE OF THE FUNIS. 

Position of the foetus — Division into dorso-anterior and dorso-posterior position 
— Causes — Prognosis and frequency — Diagnosis — Mode of distinguishing 
position of child — Differential diagnosis of shoulder, elbow, and hand — 
Mechanism — The two possible modes of delivery by the natural powers — 
Spontaneous version — Spontaneous evolution — Treatment — Complex pre- 
sentation ; foot or hand with head, hand and feet together — Dorsal dis- 
placement of the arm — Prolapse of the umbilical cord — Frequency — Prog- 
nosis — Causes — Diagnosis — Postural treatment — Artificial reposition — 
Treatment when reposition fails ........ 340 

CHAPTER IX. 

PROLONGED AND PRECIPITATE LABORS. 

Evil effects of prolonged labor — Influence of the stage of labor in protraction — 
Delay in the first stage rarely serious — Temporary cessation of pains — 
Symptoms of protraction in the second stage — State of the uterus in pro- 
tracted labor — Cases of protraction due to morbid condition of the expul- 
sive powers — Causes of protraction — Treatment — Oxytocic remedies — 
Ergot of rye, etc. — Manual pressure — Instrumental delivery (case of 
Princess Charlotte of Wales) — Precipitate labor: its causes and treatment 354 



Xll CONTENTS. 

CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

PAGE 

Rigidity of the cervix : its causes, effects, and treatment — Antepartum hour- 
glass contraction — Bands and cicatrices in the vagina — Extreme rigidity 
of the perineum — Labor complicated with tumor — Vaginal cystocele — 
Calculus — Hernial protrusions — (Edema of vulva — Haematic effusions, etc. 370 

CHAPTER XI. 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE FCETUS. 

Plural births, treatment of — Locked twins — Conjoined twins — Intra-uterine 
hydrocephalus: its dangers, diagnosis, and treatment — Other dropsical 
effusions — Foetal tumors —Excessive development of foetus — Shortness of 
the umbilical cord 383 

CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Classification — Causes of pelvic deformity — Rickets and osteomalacia — The 
equally enlarged pelvis — The equally contracted pelvis — The undeveloped 
pelvis — Masculine or funnel-shaped pelvis — Contraction of conjugate 
diameter of the brim — Scolio-rhachitic pelvis — Figure-of-eight deformity — 
Spondylolithesis — Spondylolizema — Narrowing of the oblique diameters — 
Obliquely contracted pelvis — Kyphotic pelvis— Robert's pelvis — Deformity 
from old-standing hip-joint disease— Deformity from tumors, fractures, etc. 
Effects of contracted pelvis on labor — Risks to the mother and child — 
Mechanism of delivery in head presentation : a, in contracted brim ; b, in 
generally contracted pelvis — Diagnosis — External measurements — Internal 
measurements — Mode of estimating the conjugate diameter of the brim — 
— Mode of diagnosing the oblique pelvis — Treatment — The forceps — 
Turning — Craniotomy — The induction of premature labor — Induction of 
abortion ............. 396 

CHAPTER XIII. 

HEMORRHAGE BEFORE DELIVERY: PLACENTA PREVIA. 

Definition— Causes — Symptoms —Sources and causes of hemorrhage — Prognosis 

—Treatment 420 

CHAPTER XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY-SITUATED PLACENTA. 

Causes and pathology — Symptoms and diagnosis —Prognosis — Treatment . 431 

CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 

Its frequency — Generally a preventible accident — Causes — Nature's method of 
controlling hemorrhage — Uterine contraction — Thrombosis — Secondary 



CONTENTS. XU1 



causes of hemorrhage— Irregular uterine contraction — Placental adhesions 
Constitutional predisposition to flooding — Symptoms — Preventive treat- 
ment — Curative treatment — Secondary treatment — Secondary post-partum 
hemorrhage : its causes and treatment 434 

CHAPTER XVI. 

RUPTURE OF THE UTERUS, ETC. 

Its fatality — Seat of rupture — Causes, predisposing and exciting — Symptoms — 
Prognosis — Treatment : when the foetus remains in utero ; when the foetus 
has escaped from the uterus — Lacerations of the cervix — Recapitulation — 
Lacerations of the vagina — Vesico- and recto-vaginal fistula? — Their mode 
of formation — Treatment . . 452 

CHAPTER XVII. 

INVERSION OF THE UTERUS. 

Division into acute and chronic forms — Description — Symptoms — Diagnosis — 

Mode of production — Treatment ........ 462 



PART IV. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 

INDUCTION OF PREMATURE LABOR. 

History — Objects — May be performed either on account of the mother or child 
Modes of inducing labor — Puncture of membranes — Administration of 
oxytocics — Means acting indirectly on the uterus — Dilatation of cervix — 
Separation of membranes — Vaginal and uterine douches — Injection of 
glycerin — Introduction of flexible catheter— Rearing of the child . . 468 

CHAPTER II. 

TURNING. 

History — Turning by external manipulation — Object and nature of the 
operation — Cases suitable for the operation — Statistics and dangers — 
Method of performance — Cephalic version — Method of performance — 
Podalic version — Position of patient — Administration of anaesthetics — 
Period when the operation should be undertaken — Choice of hand to be 
used — Turning by bipolar method — Turning when the hand is introduced 
into the uterus — Turning in abdomino-anterior positions — Difficult cases 
of arm presentation ........... 478 



XIV CONTEXTS. 

CHAPTER III. 

THE FORCEPS. 

PAGE 

Frequent use of the forceps in modern practice — Description of the instrument 
— The short forceps — Its varieties— The long forceps — Suitable to all cases 
alike — Action of the instrument — Its power as a tractor, lever, and com- 
pressor — Preliminary considerations before operation— Use of anaesthetics 
— Description of the operation— Low forceps operation — High forceps 
operation — Possible dangers of forceps delivery — Possible risks to the 
child 493 

CHAPTER IV. 

THE VECTIS — THE FILLET. 

Nature of the vectis — Its use as a lever or tractor — Cases in which it is appli- 
cable — Its use as a rectifier of malpositions — The fillet — Nature of the 
instrument — Objection to its use ........ 509 

CHAPTER V. 

OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 

Their antiquity and history — Division of subject — Nature of instruments em- 
ployed — Perforator — Crotchet — Craniotomy forceps — Cephalotribe — For- 
ceps saw — Ecraseur — Basilyst — Cases requiring craniotomy — Method of 
perforation — Extraction of the head — Comparative merits of cephalotripsy 
and craniotomy — Extraction by the craniotomy forceps — Extraction of the 
body — Embryotomy — Decapitation and evisceration 511 

CHAPTER VI. 

THE CESAREAN SECTION — PORRO's OPERATION. 

History of the operation — Statistics — Results to mother and child — Causes re- 
quiring the operation — Post-mortem Cesarean section — Causes of death 
after the Csesarean section — Preliminary preparations — Description of the 
operation — Subsequent management — Porro's operation — Substitutes for 
the Csesarean section 526 

CHAPTER VII. 

LAPARO-ELYTROTOMY AND SYMPHYSEOTOMY. 

History — Nature of the operation — Advantages over the Cesarean section — 
Outline of the operation — Symphysiotomy — History — Limits of the opera- 
tion—Dangers of the operation — Method of performance — Subsequent 
results 539 

CHAPTER VIII. 

THE TRANSFUSION OF BLOOD. 

History — Nature and object of the operation— Use of blood taken from the 
lower animals — Difficulties from coagulation of fibrin— Modes of obviating 



CONTENTS. XV 



PAGE 



them — Immediate transfusion — Addition of chemical agents to prevent 
coagulation — Defibrination of the blood — Injection of saline solutions — 
Statistical results — Possible dangers of the operation— Cases suitable for 
transfusion — Description of the operation — Schafer's directions for imme- 
diate transfusion — Effects of successful transfusion — Secondary effects of 
transfusion .........:.. 546 



PART V. 

THE PUERPERAL STATE. 



CHAPTER I. 

THE PUERPERAL STATE AND ITS MANAGEMENT. 

Importance of studying the puerperal state — The mortality of childbirth — 
Alterations in the blood after delivery — Condition after delivery — Nervous 
shock — Fall of the pulse — The secretions and excretions— Secretion of milk 
— Changes in the uterus after delivery — The lochia — The after-pains — 
Management of women after delivery — Treatment of severe after-pains — 
Diet and regimen ........... 557 

CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of respiration after the birth of the child — Apparent death of 
the newborn child — Its treatment — Washing and dressing the child — 
Application of the child to the breast— The colostrum and its properties — 
Secretion of milk — Importance of nursing — Selection of a wet-nurse — 
Management of lactation — Diet and regimen of nursing women — Period of 
weaning— Disorders of lactation — Means of arresting the secretion of milk 
Defective secretion of milk — Depressed nipples— Fissures and excoriations 
of the nipples — Excessive flow of milk — Mammary abscess — Hand-feeding 
Causes of mortality in hand-feeding — Various kinds of milk — Method of 
hand-feeding — Sterilization of milk— Other kinds of food . . . 568 

CHAPTER III. 

PUEKPERAL ECLAMPSIA. 

Its doubtful etiology — Premonitory symptoms — Symptoms of the attack — Con- 
dition between the attacks — Relation of the attacks to labor — Results to 
mother and child — Pathology — Treatment — Obstetric management . . 585 

CHAPTER IV. 

PUERPERAL INSANITY. 

Classification — Proportion of various forms — Insanity of pregnancy — Predis- 
posing causes — Period of pregnancy at which it occurs — Type of insanity 



XVI CONTENTS 



PAGE 



Prognosis — Transient mania during delivery — Puerperal insanity (proper) 
— Type of insanity — Causes — Theory of its dependence on a morbid state 
of the blood— Objections to the theory— Prognosis — Post-mortem signs — 
Duration — Insanity of lactation — Type — Symptoms — Of mania — Of melan- 
cholia — Treatment — Question of removal to asylum — Treatment during 
convalescence 594 

CHAPTER V. 

PUERPERAL SEPTIC DISEASE. 

Differences of opinion — Confusion from this cause — Modern view of this disease 
— History — Its mortality in lying-in-hospitals — Numerous theories as to 
its nature — Theory of local origin — Theory of an essential zymotic fever 
— Theory of its identity with surgical septicaemia — Nature of this view — 
Channels through which septic matter may be absorbed — Character and 
origin of septic matter often obscure — Division into autogenetic and 
heterogenetic cases — Objections to term " autogenetic " — Can autoinfection 
occur? — Sources of saprsemia— Sources of heterogenetic infection — Influ- 
ence of cadaveric poison — Infection from erysipelas — Infection from other 
zymotic diseases — Infection from sewer gas — Cases illustrating this mode 
of infection — Contagion from other puerperal patients — Mode in which 
the poison may be conveyed to the patient — Conduct of the practitioner in 
relation to the disease — Nature of the septic poison — Bacteriology — Local 
changes resulting from the absorption of septic material — Channels through 
which systemic infection is produced — Pathological phenomena observed 
after general blood infection — Four principal types of pathological change 
— Intense cases, without marked post-mortem signs — Cases characterized by 
inflammation of the serous membranes — Cases characterized by the im- 
paction of infected emboli, and secondary inflammation and abscess — 
Description of the disease — Duration — Varieties of symptoms in different 
cases — Symptoms of local complications — Treatment .... 605 

CHAPTER, VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal thrombosis and its results — Conditions which favor thrombosis — 
Conditions which favor coagulation in the puerperal state — Distinction 
between thrombosis and embolism — Is primary thrombosis of the pulmon- 
ary arteries possible? — History— Symptoms of pulmonary obstruction — 
Is recovery possible? — Causes of death — Post-mortem appearances— Treat- 
ment — Puerperal embolic pneumonia : its causes and treatment . . 642 

CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

Causes — Symptoms — Treatment ......... 654 



CONTENTS 



XV11 



CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE PUERPERAL, STATE. 

PAGE 

Organic and functional causes — Idiopathic asphyxia — Pulmonary apoplexy — 
Cerebral apoplexy — Syncope — Shock and exhaustion — Entrance of air 
into the veins ............ 656 

CHAPTER IX. 

PERIPHERAL. VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS — PHLEGMASIA 
DOLENS — ANASARCA SEROSA — OEDEMA LACTEUM — WHITE LEG, ETC.). 

Nature — Symptoms — History and pathology — Anatomical form of the thrombi 

in the veins — Detachment of emboli — Treatment . . . . . 659 

CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

Two forms of disease — Variety of nomenclature — Importance of differential 
diagnosis — Etiology — Connection with septicaemia — Seat of inflammation 
— Relative frequency of the two forms of disease — Symptomatology — Re- 
sults of physical examination — Terminations — Prognosis — Treatment . 666 



Index 



675 






THE SCIENCE AND PRACTICE 



OF 



MIDWIFERY. 



PART I 



ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 

IN PARTURITION. 



CHAPTEE I. 

ANATOMY OF THE PELVIS. 

The pelvis is the bony basin situated between the trunk and the 
lower extremities. To the obstetrician its study is of paramount 
importance ; for it not only contains, in the unimpregnated state, all 
the organs connected with the function of reproduction, but through 
its cavity the foetus has to pass in the process of parturition. An 
accurate knowledge, therefore, of its anatomical formation may be 
said to be the very alphabet of obstetrics, without Avhich no one can 
practise midwifery, either with satisfaction to himself or safety to his 
patient. 

In a treatise on obstetrics, however, any detailed account of the 
purely descriptive anatomy of the pelvis would be out of place. A 
knowledge of that must be taken for granted, and it is only necessary 
to refer to those points which have a more or less direct bearing on 
the study of its obstetrical relations. 

The pelvis is formed of four bones. On either side are the ossa in- 
nominata, joined together by the sawum ; to the inferior extremity of 
the sacrum is attached the coccyx, which is, in fact, its continuation. 

The os innominatum (Fig. 1) is an irregularly shaped bone 
originally formed of three distinct portions, the ilium, the ischium, 
and the pubes, which remain separated from each other up to and 
beyond the period of puberty. They are united at the acetabulum by 
a Y-shaped cartilaginous junction, which does not, as a rule, become 

3 



34 ORGANS CONCERNED IN PARTURITION. 

ossified until about the twentieth year. The consequence is that the 
pelvis, during the period of growth, is subject to the action of various 
mechanical influences to a far greater extent than in adult life ; and 
these, as we shall presently see, have an important effect in deter- 
mining the form of the bones. The external surface and borders of 
the os innominatum are chiefly of obstetric interest from giving attach- 
ment to muscles, many of which have an important accessory influence 
on parturition, such as the muscles forming the abdominal wall, which 
are attached to its crest, and those closing its outlet and forming the 
perineum, which are attached to the tuberosity of the ischium. On 
the anterior and posterior extremities of the crest of the ilium are 
two prominences (the anterior and posterior spinous processes) which 
are points from which certain measurements are sometimes taken. 
The internal surface of the upper fan-shaped portion of the os innomi- 
natum gives attachment to the iliacus muscle, and contributes to the 

Fig. 1. 




Os innominatum. 

support of the abdominal contents ; along with its fellow of the oppo- 
site side it forms the false pelvis. The false is separated from the true 
pelvis by the ilio-pectineal line, which, with the upper margin of the 
sacrum, forms the brim of the pelvis. This is of special obstetric 
importance, as it is the first part of the pelvic cavity through which 
the child passes, and that in which osseous deformities are most often 
met with. At one portion of the ilio-pectineal line, corresponding 
Avith the junction of the ilium and pubes, is situated a prominence, 
which is known as the ilio-pectineal eminence. 

The internal smooth surface of the innominate bone below the 
linea ilio-pectinea forms the greater portion of the pelvis proper. In 
front, with the corresponding portions of the opposite bone, it forms 
the arch of the pubes, under which the head of the child passes in 
labor. 

Behind this we observe the oval obturator foramen, and below that 
the tuberosity and spine of the ischium, the latter separating the great 



ANATOMY OF THE PELVIS. 



35 




and lesser sciatic notches, and giving attachment to ligaments of 
importance. The rough articulating surface posteriorly, by which the 
junction with the sacrum is effected, may be noted, and above this the 
prominence to which the powerful ligaments joining the sacrum and os 
innominatum are attached. 

The sacrum (Fig. 2) is a triangular and somewhat spongy bone 
forming the continuation of the spinal column, and binding together 
the ossa innominata. It is originally 
composed of five separate portions, anal- 
ogous to the vertebrae, which ossify and 
unite about the period of puberty, leaving 
on its internal surface four prominent 
ridges at the sites of junction. The 
upper of these is sometimes so well 
marked as to be mistaken, on vaginal 
examination, for the promontory of the 
sacrum itself. 

The base of the sacrum is about 4J 
inches in width, and its sides rapidly 
approximate until they nearly meet at 
its apex, giving the whole bone a trian- 
gular or wedge shape. The anterior and 
posterior surfaces also approximate in 
the same way, so that the bone is much 
thicker at the base than at the apex. 
The sacrum, in the erect position of 

the body, is directed from above downward, and from before back- 
ward. At its upper edge it is joined, the lumbo-sacral cartilage inter- 
vening, with the fifth lumbar vertebra. The point of junction, called 
the promontory of the sacrum, is of great importance, as on its undue 
projection many deformities of the brim of the pelvis depend. The 
anterior surface of the bone is concave, and forms the curve of the 
sacrum; more marked in some cases than in others. There is also 
more or less concavity from side to side. On it we observe four aper- 
tures on each side, the intervertebral foramina, giving exit to nerves. 
The posterior surface is convex, rough, and irregular, for the attach- 
ment of ligaments and muscles, and showing a ridge of vertical promi- 
nences corresponding to the spinous processes of the vertebrae. 

The sacrum is generally described as forming a keystone to the arch 
constituted by the pelvic bones, and transmitting the weight of the 
body, in consequence of its wedge-like shape, in a direction which 
tends to thrust it downward and backward, as if separating the ossa 
innominata. Dr. Duncan, 1 however, has shown, from a careful con- 
sideration of its mechanical relations, that it should rather be regarded 
as a strong transverse beam, curved on its anterior surface, the extremi- 
ties of which are in contact with the corresponding articular surfaces 
of the ossa innominata. The weight of the body is thus transmitted 
to the innominate bones, and through them to the acetabula and the 



Sacrum and coccyx. 



1 Researches in Obstetrics, p. 



36 ORGANS CONCERNED IN PARTURITION. 

femora (Fig. 3). There counter-pressure is applied, and the result is, 
as we shall subsequently see, an important modifying influence on the 
development and shape of the pelvis. 

The coccyx (Fig. 2) is composed of four small separate bones, 
which eventually unite into one, but not until late in life. The upper- 
most of these articulates with the apex of the sacrum. On its posterior 
surface are two small cornua, which unite with corresponding points at 
the tip of the sacrum. The bones of the coccyx taper to a point. To 
it are attached various muscles which have the effect of imparting con- 
siderable mobility. During labor, also, it yields to the mechanical 
pressure of the presenting part, so as to increase the antero-posterior 
diameter of the pelvic outlet to the extent of an inch or more. 

If, through disease or accident, as sometimes happens, the articular 
cartilages of the coccyx become prematurely ossified, the enlargement ' 
of the pelvic outlet during labor may be prevented, and considerable 
difficulty may thus arise. This is most apt to happen in aged prim- 
iparse, or in women who have followed sedentary occupations ; and 
not infrequently, under such circumstances, the bone fractures under 
the pressure to which it is subjected by the presenting part. 

Pelvic Articulations. — The pelvic bones are firmly joined together 
by various articulations and ligaments. The latter are arranged so as 
to complete the canal through which the foetus has to pass, and which 
is in great part formed by the bones. On its internal surface, where 
the absence of obstruction is of importance, they are everywhere 
smooth ; while externally, where strength is the desideratum, they 
are arranged in larger masses, so as to unite the bones firmly together. 
The pelvic articulations have been generally described as symphyses 
or amphiarthrodia, a term which is properly applied to two articulating 
surfaces united by fibrous tissue in such a way as to prevent any 
sliding motion. It is certain, however, that this is not the case witii 
the joints of the female pelvis during pregnancy and parturition. 
Lenoir found that in 22 females, between the ages of eighteen and 
thirty-five, there was a distinct sliding motion. Therefore, the pelvic 
articulations are, strictly speaking, to be considered examples of the 
class of joints termed arthrodia. 

Lumbo-sacral Joint. — The last lumbar vertebra is united to the 
sacrum by ligamentous union similar to that which joins the vertebrae 
to each other. The intervening fibro-cartilage forms a disk, which is 
thicker in front than behind, and this, in connection with a similar 
peculiarity of the fifth lumbar vertebra, tends to increase the sloped 
position of the sacrum, and the angle which it forms with the vertebral 
column. It constitutes the most prominent portion of the promontory 
of the sacrum, and is the part on which the finger generally impinges 
in vaginal examinations. The anterior common vertebral ligament 
passes over the surface of the joints, and we also find the ligamenta 
subflava and the inter-spinous ligaments, as in the other vertebrae. 
The articular processes are joined together by a fibrous capsule, and 
there is also a peculiar ligament, the lumbo-sacral, extending from the 
transverse process of the vertebra on each side, and attaching itself to 
the sides of the sacrum and the sacro-iliac synchondrosis. 



ANATOMY OF THE PELVIS. 37 

Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, 
in some cases at least, the separate bones of the coccyx to each other, 
by small cartilaginous disks like that connecting the sacrum with the 
last lumbar vertebra. They are further united by anterior and pos- 
terior common ligaments, the latter being much the thicker and more 
marked. In the adult female a synovial membrane is found between 
the sacrum and coccyx, and it is supposed that this is formed under 
the influence of the movements of the bones on each other. 

Sacro-iliac Synchondrosis. — The opposing articular surfaces of 
the sacrum and ilium are each covered by cartilages, that of the sacrum 
being the thicker. These are firmly united, but, in the female, accord- 
ing to Mr. AVood, 1 they are always more or less separated by an inter- 
vening synovial membrane. Posterior to these cartilaginous convex 
surfaces there are strong interosseous ligaments, passing directly from 
bone to bone, filling up the interspace between them, and uniting them 
firmly. There are also accessory ligaments, such as the superior and 
anterior-sacro iliac, which are of secondary consequence. The pos- 
terior sacro-iliac ligaments, however, are of great obstetric importance. 
They are the very strong attachments which unite the rough surfaces 
on the posterior iliac tuberosities to the posterior and lateral surfaces 
of the sacrum. They pass obliquely downward from the former 
points, and suspend, as it were, the sacrum from them. According to 
Duncan, the sacrum has nothing to prevent its being depressed by 
the weight of the body but these ligaments, and it is mainly through 
them that the weight of the body is transmitted to the sacro-cotyloid 
beams and the heads of the femora. 

The sacro-sciatic ligaments are instrumental in completing the 
canal of the pelvis. The greater sacro-sciatic ligament is attached by 
a broad base to the posterior inferior spine of the ilium, and to the 
posterior surfaces of the sacrum and coccyx. Its fibres unite into a 
thick cord, cross each other in an X-like manner, and again expand 
at their insertion into the tuberosity of the ischium. The lesser sacro- 
sciatic ligament is also attached with the former to the back parts of the 
sacrum and coccyx, its fibres passing to their much narrower insertion 
at the spine of the ischium, and converting the sacro-sciatic notch into 
a complete foramen. 

The obturator membrane is the fibrous aponeurosis that closes the 
large obturator foramen. Joulin 2 supposes that along with the sacro- 
sciatic ligaments, it may, by yielding somewhat to the pressure of the 
foetal head, tend to prevent the contusion to which the soft parts would 
be subjected if they were compressed between tAvo entirely osseous 
surfaces. 

Symphysis Pubis. — The junction of the pubic bones in front is 
effected by means of two oval plates of fibro-cartilage, attached to 
each articular surface by nipple-shaped projections, which fit into cor- 
responding depressions in the bones. There is a greater separation 
between the bones in front than behind, where the numerous fibres of 
the cartilaginous plates intersect, and unite the bones firmly together. 

1 Todd's Cyclopaedia ot Anatomy and Physiology, article " Pelvis," p. 123. 

2 Traite d'Accouchements, p. 11. 



38 



ORGANS CONCERNED IN PARTURITION, 



At the upper and back part of the articulation there is an interspace 
between the cartilages, which is lined by a delicate membrane. In 
pregnancy this space often increases in size, so as to extend even to the 
front of the joint. The juncture is further strengthened by four liga- 
ments, the anterior, the posterior, the superior, and the sub-pubic. Of 
these, the last is the largest, connecting together the pubic bones and 
forming the upper boundary of the pubic arch. 

Fig. 3. 




Section of pelvis and heads of thigh-bones, showing the suspensory action of the sacro-iliac 
ligaments. (After Wood.) 

Movements of Pelvic Joints. — The close apposition of the bones 
of the pelvis might not unreasonably lead to the supposition that no 
movement took place between its component parts ; and this is the 
opinion which is even yet held by many anatomists. It is tolerably 
certain, however, that even in the unimpregnated condition there is a 
certain amount of mobility. Thus Zaglas has pointed out 1 that in man 
there is a movement in an antero-posterior direction of the sacro-iliac 
joints which has the effect, in certain positions of the body, of causing 
the sacrum to project downward to the extent of about a line, thus nar- 
rowing the pelvic brim, tilting up the point of the bone, and thereby 
enlarging the outlet of the pelvis. This movement seems habitually 
brought into play in the act of straining during defecation. 

During pregnancy in some of the lower animals there is a very 
marked movement of the pelvic articulations, which materially facili- 
tates the process of parturition. This, in the case of the guinea-pig 
and cow, has been especially pointed out by Dr. Matthews Duncan. 1 
In the former during labor the pelvic bones separate from each other 

i Monthly Journal of Medical Science, Sept. 1851. 
2 Researches in Obstetrics, p. 19. 



ANATOMY OF THE PELVIS. 39 

to the extent of an inch or more. In the latter the movements are 
different, for the symphysis pubis is fixed by bony ankylosis, and is 
immovable; but the sacro-iliac joints become swollen during pregnancy, 
and extensive movements in an antero-posterior direction take place 
in them, which materially enlarge the pelvic canal during labor. 

It is extremely probable that similar movements take place in 
women, both in the symphysis pubis and in the sacro-iliac joints, 
although to a less marked extent. These are particularly well described 
by Dr. Duncan. They seem to consist chiefly in an elevation and 
depression of the symphysis pubis, either by the ilia moving on the 
sacrum, or by the sacrum itself undergoing a forward movement on 
an imaginary transverse axis passing through it, thus lessening the 
pelvic brim to the extent of one or even two lines, and increasing, at 
the same time, the diameter of the outlet, by tilting up the apex of 
the sacrum. These movements are only an exaggeration of those 
which Zaglas describes as occurring normally during defecation. The 
instinctive positions which the parturient woman assumes find an 
explanation in these observations. During the first stage of labor, when 
the head is passing through the brim, she sits, or stands, or walks about, 
and in these erect positions the symphysis pubis is depressed, and the 
brim of the pelvis enlarged to its utmost. As the head advances 
through the cavity of the pelvis, she can no longer maintain her erect 
position, and she lies down and bends her body forward, which has 
the effect of causing a nutatory motion of the sacrum, with correspond- 
ing tilting up of its apex, and an enlargement of the outlet. 

These movements during parturition are facilitated by the changes 
which are known to take place in the pelvic articulations during preg- 
nancy- The ligaments and cartilages become swollen and softened, 
and the synovial membranes existing between the articulating surfaces 
become greatly augmented in size and distended with fluid. These 
changes act by forcing the bones apart, as the swelling of a sponge 
placed between them might do after it had imbibed moisture. The 
reality of these alterations receives a clinical illustration from those 
oases, which are far from uncommon, in which these changes are 
carried to so extreme an extent that the power of progression is 
materially interfered with for a considerable time after delivery. 

On looking at the pelvis as a whole, we are at once struck with its 
division into the true and false pelvis. The latter portion (all that is 
above the brim of the pelvis) is of comparatively little obstetric impor- 
tance, except in giving attachments to the accessory muscles of parturi- 
tion, and need not be farther considered. The brim of the pelvis is a 
heart-shaped opening, bounded by the sacrum behind, the linea ilio- 
pectinea on either side, and the symphysis of the pubes in front. All 
below it forms the cavity, which is bounded by the hollow of the 
sacrum behind, by the inner surfaces of the innominate bones at the 
sides, and by the posterior surface of the symphysis pubis in front. 
It is in this part of the pelvis that the changes in direction which 
the foetal head undergoes in labor are imparted to it. The lower 
border of this canal, or pelvic outlet (Fig. 4), is lozenge-shaped, is 
bounded by the ischiatic tuberosities on either side, the tip of the 



40 



ORGANS CONCERNED IN PARTURITION. 



coccyx behind, and the under surface of the pubic symphysis in front, 
Posteriorly to the tuberosities of the ischia the boundaries of the outlet 
are completed by the sacro-sciatic ligaments. 



Fig. 4. 




Outlet of pelvis. 

There is a very marked difference between the j^elvis in the male 
and the female, and the peculiarities of the latter all tend to facilitate 
the process of parturition. In the female pelyis (Fig. 5) all the bones 
are lighter in structure, and have the points for muscular attachments 
much less developed. The iliac bones are more spread out, hence the 
greater breadth which is observed in the female figure, and the pecu- 
liar side-to-side movement which all females have in walking. The 
tuberosities of the ischia are lighter in structure and farther apart, and 
the rami of the pubes also converge at a much less acute angle. This 
greater breadth of the pubic arch gives one of the most easily appreci- 
able points of contrast between the male and the female pelyis ; the 

Fig 5. 




The female pelvis. 



pubic arch in the female forms an angle of from 90° to 100°, while 
in the male (Fig. 6) it averages from 70° to 75°. The obturator 
foramina are more triangular in shape. 



ANATOMY OF THE PELVIS, 



41 



The whole cavity of the female pelvis is wider and less funnel- 
shaped than in the male, the symphysis pubis is not so deep, and, as 
the promontory of the sacrum does not project so much, the shape of 
the pelvic brim is more oval than in the male. These differences 
between the male and female pelvis are probably due to the presence 




The male pelvis. 



of the female genital organs in the true pelvis, the growth of which 
increases its development in width. In proof of this, Schroeder states 
that in women with congenitally defective internal organs, and in 
women who have had both ovaries removed early in life, tho pelvis 
has always more or less of the masculine type. 










Brim of pelvis, showing antero-posterior, c. V, oblique, D, and transverse, t, diameters. 

Measurements of the Pelvis. — The measurements of the pelvis 
that are of most importance from an obstetric point of view are taken 
between various points directly opposite to each other, and are known 
as the diameters of the pelvis. Those of the true pelvis are the diam- 
eters which it is especially important to fix in our memories, and it is 
customarv to describe three in works on obstetrics — the antero-posterior 



42 ORGANS CONCERNED IN PARTURITION. 

or conjugate, the oblique, and the transverse — although, of course, the 
measurements may be taken at any opposing points in the circumfer- 
ence of the bones. The antero-posterior (diameter Conjugata vera, 
c. V, saero-pubic), at the brim (Fig. 7), is taken from the upper part of 
the posterior surface of the symphysis pubis to the centre of the promon- 
tory of the sacrum ; in the cavity, from the centre of the symphysis 
pubis to a corresponding point in the body of the third piece of the 
sacrum ; and at the outlet (coccy-pubic), from the lower border of the 
symphysis pubis to the tip of the coccyx. The oblique (diameter 
Diagonalis, d), at the brim, is taken from the sacro-iliac joint on either 
side to a point of the brim corresponding with the ilio-pectineal emi- 
nence — that starting from the right sacro-iliac joint being called the 
right oblique (diameter Diagonalis dextra, D. d), that from the left the 
left oblique (diameter Diagonalis sinistra, D. s) ; in the cavity a similar 
measurement is made at the same level as the conjugate ; while at the 
outlet an oblique diameter is not usually measured. The transverse 
(diameter Transversa, t) is taken, at the brim, from a point midway 
between the sacro-iliac joint and the ilio-pectineal eminence to a cor- 
responding point at the opposite side of the brim ; in the cavity, from 
points in the same plane as the conjugate and oblique diameters ; and 
at the outlet, from the centre of the inner border of one ischial tuber- 
osity to that of the other. The measurements given by various writers 
differ considerably and vary somewhat in different pelves. Taking the 
average of a large number, the following may be given as the standard 
measurements of the female pelvis : 

Antero-posterior, Oblique, Transverse, 

c. v. o. T. 

Inches. Inches. Inches. 

Brim 4.25 4.8 5.2 

Cavity 4.7 5.2 4.75 

Outlet 5.0 — 4.2 

It will be observed that the lengths of the corresponding diameters 
at different places vary greatly ; thus, while the transverse (t) is longest 
at the brim, the oblique (d) is longest in the cavity, and the antero- 
posterior (c. v) at the outlet. It will be subsequently seen that this 
fact is of great practical importance in studying the mechanism of 
delivery, for the head in its descent through the pelvis alters its posi- 
tion in such a w T ay as to adapt itself to the longest diameter of the 
pelvis ; thus, as it passes through the cavity it lies in the oblique (d) 
diameter, and then rotates so as to be expelled in the antero-pos- 
terior (c. v) diameter of the outlet. 

In thinking of these measurements of the pelvis, it must not be 
forgotten that they are taken in the dried bones, and that they are 
considerably modified during life by the soft parts. This is especially 
the case at the brim, w T here the projection of the psoas and iliacus 
muscles lessens the transverse (t) diameter about half an inch, while 
the antero-posterior (c. v) diameter of the brim, and all the diameters 
of the cavity, are lessened by a quarter of an inch. The right oblique 
diameter (d. d) of the brim is, even in the dried pelvis, found to be on 
an average slightly longer than the left (d. s), probably on account of 
the increased development of the right side of the pelvis from the greater 



ANATOMY OF THE PELVIS 



43 



Fig. 



use made of the right leg ; but, in addition to this, the left oblique 
diameter (d. s) is somewhat lessened during life by the presence of 
the rectum on the left side. The 
advantage gained by the com- 
paratively frequent passage of the 
head through the pelvis in the 
right oblique diameter (d. d) is 
thus explained. 

There are one or two other 
measurements of the true pelvis 
which are sometimes given, but 
which are of secondary impor- 
tance. One of these, the sacro- 
cotyloid diameter, is that between 
the promontory of the sacrum and 
a point immediately above the 
cotyloid cavity, and averages from 
3.4 to 3.5 inches. Another, called 
by Wood the lower or inclined 
conjugate diameter (diameter Con- 
jugata diagonalis, c. d), is that be- 
tween the centre of the lower mar- 
gin of the symphysis pubis and 
the promontory of the sacrum, and 
averages half an inch more than 
the antero-posterior diameter of 
the brim. A third is between the 
ischial tuberosities, averaging 4J 
inches. These measurements are 
chiefly of importance in relation to 
certain pelvic deformities. 

The external measurements 
of the pelvis are of no real conse- 
quence in normal parturition, but 
they may help us, in certain cases, 
to estimate the existence and 
amount of deformities. Those 

which are generally given are : Between the anterior superior iliac 
spines (inter-spinal), 10 inches ; between the central points of the 
crests of the ilia (inter-cristal), 10J inches ; between the spinous pro- 
cess of the last lumbar vertebra and the upper part of the symphysis 
pubis (external conjugate), 7 J- inches. 

Planes of the Pelvis. — By the planes of the pelvis are meant imagi- 
nary levels at any portion of its circumference. If we were to cut out 
a piece of cardboard so as to fit the pelvic cavity, and place it either at 
the brim or elsewhere, it would represent the pelvic plane at that par- 
ticular part, and it is obvious that we may conceive as many planes as 
we desire. Observation of the angle which the pelvic planes form 
with the horizon shows the great obliquity at which the pelvis is placed 
in regard to the spinal column. Thus the angle A B I (Fig. 9) repre- 




Section of pelvis, showing the diameters. 



44 



ORGANS CONCERNED IN PARTURITION 



sents the inclination to the horizon of the plane of the pelvic brim, i b, 
and is estimated to be about 60°, while the angle which the same plane 
forms with the vertebral column is about 150°. The plane of the out- 
let forms, with the coccyx in its usual position, an angle with the hori- 
zon of about 11°, but which varies greatly with the movements of the 
tip of the coccyx, and the degree to which it is pushed back during 
parturition. These figures must only be taken as giving an approxi- 
mate idea of the inclination of the pelvis to the spinal column, and it 




D 

Planes of the pelvis with horizon, a b. Horizon, c d. Vertical line, a b i. Angle of inclina- 
nation of pelvis to horizon, equal to 60°. bic. Angle of inclination of pelvis to spinal column, 
equal to 150°. cu. Angle of inclination of sacrum to spinal column, equal to 130°. e f. Axis of 
pelvic inlet, l m. Mid-plane in the middle line. n. Lowest point of mid-plane of ischium. 

must be remembered that the degree of inclination varies considerably 
in the same female at different times, in accordance with the position 
of the body. During pregnancy especially, the obliquity of the brim 
is lessened by the patient throwing herself, backward in order to sup- 
port more easily the weight of the gravid uterus. The height of the 
promontory of the sacrum above the upper margin of the symphysis 
pubis is, on an average, about three and three-quarters inches, and a 
line passing horizontally backward from the latter point would im- 
pinge on the junction of the second and third coccygeal bones. 

Axes of the Parturient Canal. — By the axis of the pelvis is meant 
an imaginary line which indicates the direction which the foetus takes 
during its expulsion. The axis of the brim (Fig. 10) is a line drawn 
perpendicular to its plane, which would extend from the umbilicus to 
about the apex of the coccyx ; the axis of the outlet of the bony pelvis 
intersects this, and extends from the centre of the promontory of the 
sacrum to midway between the tuberosities of the ischia. The axis of 



ANATOMY OF THE PELVIS. 
Fig. 10. 



45 




Axes of the pelvis, a. Axis of superior plane, b. Axis of mid-plane, c. Axis of inferior plane. 
d. Axis of canal, e. Horizon. 

the entire pelvic canal is represented by the sum of the axes of an 
indefinite number of planes at different levels of the pelvic cavity, 
which forms an irregular parabolic line, as represented in the accom- 
panying diagram (Fig. 10, a d). 

Fig. ll. 




Representing general axis of parturient canal, including the uterine cavity and soft parts. 



46 



ORGANS CONCERNED IN PARTURITION. 



Fig. 12. 



It must be borne in mind, however, that it is not the axis of the 
bony pelvis alone that is of importance in obstetrics. We must always 
remember, in considering this subject, that the general axis of the par- 
turient canal (Fig. 11) also includes that of the uterine cavity above, 
and of the soft parts below. These are variable in direction according 
to circumstances ; and it is only the axis of that portion of the partu- 
rient canal extending between the plane of the pelvic brim and a plane 
between the lower edge of the pubic symphysis and the base of the 
coccyx that is fixed. The axis of the lower part of the canal will vary 
according to the amount of distention of the perineum during labor ; 
but when this is stretched to its utmost, just before the expulsion of 
the head, the axis of the plane between the edge of the distended peri- 
neum and the lower border of the symphysis looks nearly directly for- 
ward. The axis of the uterine cavity generally corresponds with that 
of the pelvic brim, but it may be much altered by abnormal positions 
of the uterus, such as anteversion from laxity of the abdominal walls. 
The foetus, under such circumstances, will not enter the brim in its 
proper axis, and difficulties in labor arise. A knowledge of the gen- 
eral direction of the parturient canal 
is of great importance in practical 
midwifery in guiding us to the intro- 
duction of the hand or instruments in 
obstetric operations, and in showing 
us how to obviate difficulties arising 
from such accidental deviations of the 
uterus as have just been alluded to. 

Cavity of the Pelvis. — The arrange- 
ments of the bones in the interior of 
the pelvic canal (Fig. 12) are impor- 
tant in relation to the mechanism of 
delivery. A line passing between the 
spine of the ischium and the ilio-pec- 
tineal eminence divides the inner sur- 
face of the ischial bone into two smooth 
plane surfaces, which have received 
the name of the planes of the ischium. 
Two other planes are formed by the inner surfaces of the pubic bones 
in front and by the upper portion of the sacrum behind, both having 
a direction downward and backward. In studying the mechanism of 
delivery, it will be seen that many obstetricians attribute to these 
planes, iu conjunction with the spines of the ischia, a very important 
influence in effecting rotation of the foetal head from the oblique to the 
antero-posterior diameter of the pelvis. 

Development of the Pelvis. — The peculiarities of the pelvis during 
infancy and childhood are of interest as leading to a knowledge of the 
manner in which the form observed during adult life is impressed upon 
it. The sacrum in the pelvis of the child (Fig. 13) is less developed 
transversely, and is much less deeply curved than in the adult. The 
pubes is also much shorter from side to side, and the pubic arch is an 
acute angle. The result of this narrowness of both the pubes and 




Side view of pelvis. 



ANATOMY OF THE PELVIS, 47 

sacrum is that the transverse (t) diameter of the pelvic brim is shorter 
instead of longer than the antero-posterior (c. v). The sides of the 
pelvis have a tendency to parallelism, as well as the antero-posterior 
walls ; and this is stated by Wood to be a peculiar characteristic of the 
infantile pelvis. The iliac bones are not spread out as in adult life, 
so that the centres of the crests of the ilia are not more distant from 
each other than the anterior superior spines. The cavity of the true 
pelvis is small, and the tuberosities of the ischia are proportionately 
nearer to each other than they afterward become ; the pelvic viscera 
are consequently crowded up into the abdominal cavity, which is, for 
this reason, much more prominent in children than in adults. The 
bones are soft and semi-cartilaginous until after the period of puberty, 
and yield readily to the mechanical influences to which they are 
subjected; and the three divisions of the innominate bone remain 
separate until about the twentieth year. 

Fig. 13. 




Pelvis of a child. 



As the child grows older the transverse development of the sacrum 
increases, and the pelvis begins to assume more and more of the adult 
shape. The mere growth of the bones, however, is not sufficient to 
account for the change in the shape of the pelvis, and it has been well 
shown by Duncan that this is chiefly produced by the pressure to which 
the bones are subjected during early life. The iliac bones are acted 
upon by two principal and opposing forces. One is the weight of the 
body above, which acts vertically upon the sacral extremity of the 
iliac beam through the strong posterior sacro-iliac ligaments, and tends 
to throw the lower or acetabular ends of the sacro-cotyloid beams out- 
ward. This outward displacement, however, is resisted, partly by the 
junction between the two acetabular ends at the front of the pelvis, 
but chiefly by the opposing force, which is the upward pressure of the 
loAver extremities through the femurs. The result of these counteract- 
ing forces is that the still soft bones bend near their junction with 
the sacrum, and thus the greater transverse development of the pelvic 
brim characteristic of adult life is established. These mechanical forces 



48 ORGANS CONCERNED IN PARTURITION. 

are to some extent aided by the action of the muscles attached to 
various parts of the pelvis. The muscles attached to the anterior half 
of the pelvis, especially the recti, tend to pull the pubes back to the 
sacrum, aud thus to increase the transverse diameter of the brim, while 
the action of the psoas aud iliacus tends to draw the upper toward the 
lower part of the pelvic ring, and this also favors transverse develop- 
ment. The altered shape of the iliac fossae after puberty is also pro- 
moted by the action of the muscles attached to them. In treating of 
pelvic deformities it will be seen that the same forces applied to dis- 
eased aud softened bones explain the peculiarities of form that they 
assume. 

Pelvis in Different Races. — The researches that have been made 
on the differences of the pelvis in different races prove that these are 
not so great as might have been expected. Joulin pointed out that in 
all human pelves the transverse (t) diameter was larger than the 
antero-posterior (c. v), while the reverse was the case in all the lower 
animals, even in the highest simise. This observation has been 
confirmed by Von Franque, 1 who has made careful measurements 
of the pelvis in various races. In the pelvis of the gorilla the oval 
form of the brim, resulting from the increased length of the con- 
jugate (c. v) diameter, is very marked. In certain races there is so 
far a tendency to animality of type that the difference between the 
transverse (t) and conjugate (c. v) diameters is much less than in 
European women, but it is not sufficiently marked to enable us to 
refer any given pelvis to a particular race. Von Franque makes the 
general observation that the size of the pelvis increases from south to 
north, but that the conjugate (c. v) diameter increases in proportion to 
the transverse (t) in southern races. 

Soft Parts in Connection "with Pelvis. — In closing the description 
of the pelvis, the attention of the student must be directed to the 
muscular and other structures which cover it. It has already been 
pointed out that the measurements of the pelvic diameters are con- 
siderably lessened by the soft parts, which also influence parturition 
in other ways. Thus, attached to the crests of the ilia are strong 
muscles which not only support the enlarged uterus during pregnancy, 
but are powerful accessory muscles in labor : in the pelvic cavity are 
the obturator and pyriformis muscles lining it on either side; the 
pelvic cellular tissue and fasciae ; the rectum and bladder • the vessels 
and nerves, pressure on which often gives rise to cramps and pains 
during pregnancy and labor ; while below, the outlet of the pelvis is 
closed, and its axis directed forward by the numerous muscles forming 
the floor of the pelvis and perineum. The structures closing the 
pelvis have been accurately described by Dr. Berry Hart, 2 who points 
out that they form a complete diaphragm stretching from the pubis to 
the sacrum, in which are three " faults" or "slits" formed by the 
orifices of the urethra, vagina, and rectum. The first of these is a 
mere capillary slit, the last is closed by a strong muscular sphincter, 
while the vagina, in a healthy condition, is also a mere slit, with its 

1 Scanzoui's Beitrage, 1867. 2 The Structural Anatomy of the Female Pelvic Floor. 



THE FEMALE GENERATIVE ORGAN'S. 49 

walls in accurate apposition. Hence it follows that none of these 
apertures impairs the structural efficiency of the pelvic floor or the 
support it gives to the structures above it. 



CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

The reproductive organs in the female are conveniently divided, 
according to their functions, into : 1. The external or copulative 
organs, which are chiefly concerned in the act of inseminatiou, and are 
only of secondary importance in parturition: they include all the 
organs situate externally which form the vulva; and the vagina, w T hich 
is placed internally and forms the canal of communication between the 
uterus and vulva. 2. The internal or formative organs : they 
include the ovaries, which are the most important of all, as being 
those in which the ovule is formed ; the Fallopian tubes, through 
which the ovule is carried to the uterus ; and the uterus, in which the 
impregnated ovule is lodged and developed. 

1. The external organs consist of: 

The mons Veneris (Fig. 14, r), a cushion of adipose and fibrous 
tissue which forms a rounded projection at the upper part of the vulva. 
It is in relation above with the lower part of the hypogastric region, 
from which it is often separated by a furrow, and below it is con- 
tinuous with the labia majora on either side. It lies over the sym- 
physis and horizontal rami of the pubes. After puberty it is covered 
with hair. On its integument are found the openings of numerous 
sweat and sebaceous glands. 

The labia majora (Fig. 14, a) form two symmetrical sides to the 
longitudinal aperture of the vulva. They have two surfaces, one 
external, of ordinary integument, covered with hair, and another 
internal, of smooth mucous membrane, in apposition with the corre- 
sponding portion of the opposite labium, and separated from the 
external surface by a free convex border. They are thicker in front, 
where they run into the mons Veneris, and thinner behind, where they 
are united, in front of the perineum, by a thin fold of integument 
called the fourchette, which is almost invariably ruptured in the first 
labor. In the virgin the labia are closely in apposition, and conceal 
the rest of the generative organs. After childbearing they become 
more or less separated from each other, and in the aged they waste, 
and the internal nymphse protrude through them. Both their cuta- 
neous and mucous surfaces contain a large number of sebaceous glands, 
opening either directly on the surface or into the hair follicles. In 

4 



50 



ORGANS CONCERNED IN PARTURITION. 



structure the labia are composed of connective tissue, containing a 
varying amount of fat, and parallel with their external surface are 
placed tolerably close plexuses of elastic tissue, interspersed with 
regularly arranged smooth muscular fibres. These fibres are described 
by Broca as forming a membranous sac, resembling the dartos of the 
scrotum, to which the labia majora are analogous. Toward its upper 
and narrower end this sac is continuous with the external inguinal 
ring, and in it terminate some of the fibres of the round ligament. 
The analogy with the scrotum is further borne out by the occasional 
hernial protrusion of the ovary into the labium, corresponding to the 
normal descent of the testis in the male. 



Fig. 14. 




External genitals of virgin with diaphragmatic hymen, a. Labium majus. &. Labium minus. 
c. Prseputium clitoridis. d. Glans clitoridis. e. Vestibule just above urethral orifice. /. Mons 
Veneris. (After Sappey.) 



The labia minora, or nymphae (Fig. 14, 6), are two folds of 
mucous membrane, commencing below, on either side, about the centre 
of the internal surface of the labium externum ; they converge as they 
proceed upward, bifurcating as they approach each other. The lower 
branch of this bifurcation is attached to the clitoris (Fig. 14, d), while 
the upper and larger unites with its fellow of the opposite side, and 
forms a fold round the clitoris, known as its prepuce, c. The nymphae 






THE FEMALE GENERATIVE ORGANS. 51 

are usually entirely concealed by the labia majora, but after child- 
bearing and in old age they project somewhat beyond them; then they 
lose their delicate pink color and soft texture, and become brown, dry, 
and like skin in appearance. This is especially the case in some of 
the negro races, in whom they form long projecting folds called the 
apron. 

The surfaces of the nymphae are covered with tessellated epithelium, 
and over them are distributed a large number of vascular papillae, 
somewhat enlarged at their extremities, and sebaceous glands, which 
are more numerous on their internal surfaces. The latter secrete an 
odorous, cheesy matter, which lubricates the surface of the vulva, and 
prevents its folds adhering to each other. The nymphae are composed 
of trabecular of connective tissue, containing muscular fibres. 

The clitoris (Fig. 14, d) is a small erectile tubercle situated about 
half an inch below the anterior commissure of the labia majora. It 
is the analogue of the penis in the male, and is similar to it in struc- 
ture, consisting of two corpora cavernosa, separated from each other 
by a fibrous septum. The crura are covered by the ischio-cavernous 
muscles, Avhich serve the same purpose as in the male. It has also a 
suspensory ligament. The corpora cavernosa are composed of a vas- 
cular plexus with numerous traversing muscular fibres. The arteries 
are derived from the internal pudic artery, which gives a branch, the 
cavernous, to each half of the organ ; there is also a dorsal artery dis- 
tributed to the prepuce. According to Gussenbauer, these cavernous 
arteries pour their blood directly into large veins, and a finer venous 
plexus near the surface receives arterial blood from small arterial 
branches. By these arrangements the erection of the organ which 
takes place during sexual excitement is favored. The nervous supply 
of the clitoris is large, being derived from the internal pudic nerve, 
which supplies branches to the corpora cavernosa, and terminates in 
the glans and prepuce, where Paccinian corpuscles and terminal bulbs 
are to be found. On this account the clitoris has been supposed by 
some to be the chief seat of voluptuous sensation in the female. 

The vestibule (Fig. 14, e) is a triangular space, bounded at its apex 
by the clitoris, and on either side by the folds of the nymphae. It is 
smooth, and, unlike the rest of the vulva, is destitute of sebaceous 
glands, although there are several groups of muciparous glands open- 
ing on its surface. In its centre is a slight ridge, not observable in 
the adult female, described by Pozzi 1 as the " vestibular band," which 
is the analogue of the cylindrical portion of the corpus spongiosum 
in the male. At the centre of the base of the triangle, which is 
formed by the upper edge of the opening of the vagina, is a promi- 
nence, distant about an inch from the clitoris, on which is the orifice 
of the urethra. This prominence can be readily made out by the 
finger, and the depression upon it — leading to the urethra — is of im- 
portance as our guide in passing the female catheter. This little 
operation ought to be performed without exposing the patient, and 
it is done in several ways. The easiest is to place the tip of the index 

1 Traite de Gyuecologie, p. 1184. 



52 ORGANS CONCERNED IN PARTURITION, 

finger of the left band (the patient lying on her back) on the apex of 
the vestibule, and slip it gently down until we feel the bulb of the 
urethra, and the dimple of its orifice, which is generally readily found. 
If there is any difficulty in finding the orifice, it is well to remember 
that it is placed immediately below the sharp edge of the lower border 
of the symphysis pubis, which will guide us to it. The catheter (and 
a male elastic catheter is always the best, especially during labor, when 
the urethra is apt to be stretched) is then passed under the thigh of the 
patient, and directed to the orifice of the urethra by the finger of the 
left hand, which is placed upon it. We must be careful that the 
instrument is really passed into the urethra, and not into the vagina. 
It is advisable to have a few feet of elastic tubing attached to the end 
of the catheter, so that the urine can be passed into a vessel under the 
bed without uncovering the patient. If the patient be on her side, in 
the usual obstetric position, the operation can be more readily per- 
formed by placing the tip of the finger in the vagina, and feeling its 
upper edge. The orifice of the urethra lies immediately above this, 
and if the catheter be slipped along the palmar surface of the finger, it 
can generally be inserted without much trouble. If, however, as is 
often the case during labor, the parts are much swollen, it may be diffi- 
cult to find the aperture, and it is then always better to look for the 
opening than to hurt the patient by long-continued efforts to feel it. 

The urethra is a canal one and a half inches in length, and it is 
intimately connected with the anterior wall of the vagina, through 
which it may be felt. In its walls are found both striped and un- 
striped muscular fibres arranged longitudinally and circularly, with 
abundance of elastic tissue. It is lined with many layers of epithe- 
lium, squamous below, and like that of the bladder above. It is 
remarkable for its extreme dilatability, a property which is turned 
to practical account in some of the operations for stone in the female 
bladder. 

About an eighth of an inch above its orifice are the openings of two 
glandular structures situated in its muscular walls. They are about 
three-quarters of an inch in length, and were first described by Pro- 
fessor Skene, of Brooklyn. 1 

The orifice of the vagina is situated immediately below the bulb 
of the urethra. In virgins it is a circular opening, but in women who 
have borne children or practised sexual intercourse it is, in the undis- 
tended state, a fissure, running transversely, and at right angles to that 
between the labia. 2 In virgins it is generally more or less blocked up 
by a fold of mucous membrane, containing some cellular tissue and 
muscular fibres, with vessels and nerves, which is known as the hymen. 
This is continuous with the anterior extremity of the vagina, the 
mucous membrane of which lines its internal surface ; that covering 
its external surface being derived from the mucous membrane of the 
vulva. 3 The hymen is developed late in the female embryo, and at 
first is seen in the form of two projections on either side of the uro- 

1 A.mer. Journ. of Obstetrics, 1880, vol. xiii. p. 265. 2 Hart : op. cit. 

3 Budin : Recherches sur 1' Hymen et l'Orifice vaginal, 1879. 



THE FEMALE GENERATIVE ORGANS. 53 

genital fissure, which ultimately unite in the central line, and extend 
upward, surrounding the orifice of the urethra, and then constituting 
the vestibular band previously mentioned. In the foetus, therefore, 
the hymen is composed of three parts i 1 1st, the hymen proper ; 2d, 
the projection surrounding the meatus (sometimes described as the 
urethral hymen) ; 3d, the vestibular band. At birth it is very promi- 
nent, and has occasionally been taken for the internal labia. 2 It is 
most often bi-labial, at other times crescentic in shape, with the con- 
cavity of the crescent looking upward ; sometimes, however, it is cir- 
cular with a central opening, or cribriform ; or it may even be entirely 
imperforate, and this gives rise to the retention of the menstrual secre- 
tion, although the majority of cases of this kind are really the result of 
atresia of the vaginal orifice. These varieties of form depend on the 
peculiar mode of development of the fold of vaginal mucous membrane 
which blocks up the orifice of the vagina in the foetus, and from which 
the hymen is formed. The density of the membrane also varies in 
different individuals. Most usually it is very slight, so as to be rup- 
tured in the first sexual approaches, or even by some accidental cir- 
cumstance, such as stretching the limbs, so that its absence cannot be 
taken as evidence of want of chastity. A knowledge of this fact is of 
considerable importance from a medico-legal point of view. Generally 
it is quite possible to introduce the examining finger in a " Virgo 
intacta" without destroying the membrane. Sometimes it is so tough 
as to prevent intercourse altogether, and may require division by the 
knife or scissors before this can be effected ; and at others it rather 
unfolds than ruptures, so that it may exist even after impregnation has 
been effected, and it has been met with intact in women who have habit- 
ually led unchaste lives. In a few rare cases it has even formed an 
obstacle to delivery, and has required incision during labor. 

The carunculse myrtiformes are small fleshy tubercles varying 
from two to five in number, situated round the orifice of the vagina, 
which are generally supposed to be the remains of the ruptured 
hymen. Schroeder, however, maintains that they are only formed 
after childbearing, in consequence of parts of the hymen having been 
destroyed by the injuries received during the passage of the child. 

Vulvo-vaginal (Hands. — Near the posterior part of the vaginal 
orifice, and below the superficial perineal fascia, are situated two con- 
glomerate glands which are the analogues of Cowper's glands in the male. 
Each of these is about the size and shape of an almond, and is contained 
in a cellular fibrous envelope. Internally they are of a yellowish - 
white color, and are composed of a number of lobules separated from 
each other by prolongations of the external envelope. These give origin 
to separate ducts which unite into a common canal, about half an inch 
in length, which opens in front of the attached edge of the hymen in 
virgins, and in married women at the base of one of the carunculae- 
myrtiformes. According to Huguier, the size of the glands varies 
much in different women, and they appear to have some connection 
with the ovary, as he has always found the largest gland to be on the 

1 Pozzi : Op. cit., p. 1184. 2 Doran : Gynecological Operations, p. 7. 



54 



ORGANS CONCERNED IN PARTURITION, 



same side as the largest ovary. They secrete a glairy? tenacious fluid, 
which is ejected in jets during the sexual orgasm, probably through 
the spasmodic action of the perineal muscles. At other times their 
secretion serves the purpose of lubricating the vulva, and thus pre- 
serves the sensibility of its mucous membrane. 

Fossa Navicularis. — Immediately behind the hymen in the unmar- 
ried, and between it and the perineum, is a small depression, called the 
fossa iiariculai-is, which disappears after childbearing. 

The perineum separates the orifice of the vagina from that of the 
rectum. It is about one and a half inches in breadth, and is of great 
obstetric interest, not only as supporting the internal organs from 
below, but because of its action in labor. It is largely stretched and 
distended by the presenting part of the child, and, if unusually tough 
and unyielding, may retard delivery, or it may be torn to a greater or 
less extent, thus giving rise to various subsequent troubles. 

Vascular Supply of the Vulva. — The structures described above 
together form the vulva, and they are remarkable for their abundant 
vascular and nervous supply. The former constitutes an erectile tissue, 
similar to that which has already been described in the clitoris, and 

Fig. 15. 




Vascular supply of vulva, a. Bulb of vestibule. 6. Muscular tissue of vagina. c,d,e,f. The 
clitoris and muscles, g, h, i, k, I, m, n. Veins of the nymphse and clitoris communicating with the 
epigastric and obturator veins. (After Kobelt.) 



which is especially marked about the bulb of the vestibule. (Fig. 15.) 
From this point, and extending on either side of the vagina, there 
is a well-marked plexus of convoluted veins, which in their distended 
state, are likened by Dr. Arthur Farre to a filled leech. The erection 
of the erectile tissue, as well as that of the clitoris, is brought about 



PLATE I 




Os Pubis 



Bladder 



Clitoris 



Rectum 



Portio 
Vaginalis 



Vagina 



Rectum 



Section of a Frozen Body in the last Month of Pregnancy. 

(After Braune.) 

Illustrating the relations of the Uterus to the surrounding parts, 

and the attitude of the Foetus, which is lying 

in the second cranial position. 



THE FEMALE GENERATIVE ORGANS, 



55 



under excitement, as in the male, by the compression of the efferent 
veins, by the contraction of the ischio-cavernons muscles, and by that 
of a thin layer of muscular tissue surrounding the orifice of the vagina, 
aud described as the constrictor vaginae. 

The vagina is the canal which forms the communication between 
the external and internal generative organs, through which the semen 
passes to reach the uterus, the menses flow, and the foetus is expelled. 
Roughly speaking, it lies in the axis of the pelvis, but its opening is 
placed anterior to the axis of the pelvic outlet, so that its lower portion 
is curved forward, so as to lie parallel to the pelvic brim. It is narrow 
below, but dilated above, where the cervix uteri is inserted into it, so 
that it is more or less conoidal in shape. Under ordinary circum- 
stances, especially in the virgin, the anterior and posterior walls lie in 
close contact with each other (see Plate I.), and there is, strictly speak- 
ing, no vaginal canal, although they are capable of wide distention, as 
in copulation, and during the passage of the foetus. The anterior wall 
of the vagina is shorter than the posterior, the former measuring on an 
average two and a half inches, the latter three inches ; but the length 
of the canal varies greatly in different subjects and under certain cir- 
cumstances. In front the vagina is closely connected with the base of 
the bladder, so that when the vagina is prolapsed, as often occurs, it 
drags the bladder with it (Fig. 17) ; behind, it is in relation with the 
rectum, but less intimately ; laterally, with the broad ligaments and 
pelvic fascia ; and superiorly, with the lower portion of the uterus and 



Fig. 16. 




Right half of virgin vagina, with walls held apart, showing the abundant transverse rugae, the 
greater depth of the vagina above than below, and the hymeneal segment. (After Hakt.) 

folds of peritoneum both before and behind. The vagina is composed 
of mucous, muscular, and cellular coats. The mucous lining is thrown 
into numerous folds. These start from longitudinal ridges which exist 
on both the anterior and posterior Avails, but most distinctly on the 
anterior. They are very numerous in the young and unmarried, and 



56 



ORGANS CONCERNED IN PARTURITION, 



Fig. 17. 




Longitudinal section of body, showing relations of generative organs. 



Fig. 18. 




Transverse section of the body, showing relations of the fundus uteri, m. Pubes. a a (in front), 
Remainder of hypogastric arteries, a a (behind). Spermatic vessels and nerves. B. Bladder. 
/ L. Round ligaments. U. Fundus uteri. 1 1. Fallopiau tubes, o o. Ovaries, r. Rectum. 
g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, v. Last lumbar vertebra 



THE FEMALE GENERATIVE ORGANS, 57 

greatly increase the sensitive surface of the vagina (Fig. 16). After 
childbearing, and in the aged, they become atrophied, but they never 
completely disappear, and toward the orifice of the vagina, where they 
exist in greatest abundance, they are always to be met with. The 
w T hole of the mucous membrane is lined with tessellated epithelium, 
and it is covered with a large number of papillae, either conical or 
divided, which are highly vascular and project into the epithelial layer. 
Unlike the vulvar mucous membrane,, that of the vagina seems to be 
destitute of glands. Beneath the epithelial layer is a submucous tissue 
containing a large number of elastic and some muscular fibres, derived 
from the muscular walls of the vagina. These are strong and well de- 
veloped, especially toward the ostium vaginae, where they are arranged 
in a circular mass, having a sphincter action. They consist of two 
layers — an internal longitudinal, and an external circular — with oblique 
decussating fibres connecting the two. Below they are attached to the 
ischio-pubic rami, and above they are continuous with the muscular 
coat of the uterus. The muscular tissue of the vagina increases in 
thickness during pregnancy, but to a much less degree than that of the 
uterus. Its vascular arrangements, like those of the vulva, are such 
as to constitute an erectile tissue. The arteries form an intricate net- 
work around the tube, and eventually end in a submucous capillary 
plexus from which twigs pass to supply the papillae ; these, again, give 
origin to venous radicles w r hich unite into meshes freely interlacing 
with each other, and forming a well-marked venous plexus. 

The bacteriology of the genital tract in women has of late attracted 
much attention in consequence of its intimate connection with various 
important morbid conditions. In the healthy woman, both in the 
virgin and in the married, numerous microbes are to be found in the 
vagina. These appear to enter from without, through the vulva. 
Amongst those most commonly observed are various species of staphy- 
lococci and streptococci, and the bacillus coli. Although these are 
often morphologically identical with those which produce purulent and 
septic infection, their virulent properties seem to be counteracted by 
the acidity of the vaginal mucus, and they are practically non-patho- 
genic. 

Doderlein 1 attributes this to the presence of a special vaginal bacillus, 
which has a germicidal effect on the microbes in consequence of its pro- 
ducing lactic acid during its development. Stroganoff, 2 who agrees 
with Doderlein, also holds that the mucus plug which is normally 
found in the cervix has active germicidal properties, thus preventing 
the access of' microbes to the more deeply-seated portions of the genital 
tract, in which, as a matter of fact, they are not found, the external 
os being the boundary beyond which they do not normally pass. 
Walthard 3 also attributes valuable safeguarding properties to the 
presence of leucocytes, produced by the admixture of the cervical and 
vaginal discharges. 

During menstruation the number of microbes in the vagina is largely 

1 Das Scheidensekret und seine Bedeutung fiir des Puerperalneber. Leipzig. 1892. 

2 Monat. f. Geb. und Gyn. Bd. ii. 3 Deutsche med. Wochenschrift, October 24, 1894. 



58 ORGANS CONCERNED IN PARTURITION. 

increased. During pregnancy, on the other hand, their number is 
greatly lessened. This is due, it would appear, to the increased amount 
and acidity of the vaginal secretion co-existing with pregnancy, which 
is, therefore, in effect of a salutary and antiseptic nature. 

It will be seen, when we discuss the subject of puerperal septic dis- 
ease, that these observatious have an important bearing on the origin 
of that form of disease, and on Nature's methods of protecting women 
from the risk of its development after labor. 

2. The internal organs of generation consist of the uterus, the 
Fallopian tubes, and the ovaries ; and in connection with them we have 
to study the various ligaments and folds of peritoneum which serve 
to maintain the organs in position, along with certain accessory struc- 
tures. Physiologically, the most important of all the generative organs 
are the ovaries, in which the ovules are formed, and which dominate 
the entire reproductive life of the female. The Fallopian tubes, which 
convey the ovule to the uterus, and the uterus itself — whose main 
function is to receive, nourish, and eventually expel the impregnated 
product of the ovary — may be said to be, in fact, accessory to these 
viscera. Practically, however, as obstetricians, we are chiefly con- 
cerned with the uterus, and may conveniently commence with its 
description. 

The uterus is correctly described as a pyriform organ, flattened 
from before backward, consisting of the body, with its rounded fundus, 
and the cervix, which projects into the upper part of the vaginal canal. 
In the adult female it is deeply situated in the pelvis, being placed 
between the bladder in front and the rectum behind, its fundus being 
below the plane of the pelvic brim (Fig. 18). It only assumes this 
position, however, toward the period of- puberty ; and in the foetus it 
is placed much higher, and lies, indeed, entirely within the cavity of 
the abdomen. It is maintained in this position partly by being slung 
by its ligaments, which we shall subsequently study, and partly by 
being supported from below by the pelvic cellular tissue and the fleshy 
column of the vagina. The result is that the uterus, in the healthy 
female, is a perfectly movable body, altering its position to suit the 
condition of the surrounding viscera, especially the bladder and rectum, 
which are subjected to variations of size according to their fulness or 
emptiness. When from any cause the mobility of the organ is inter- 
fered with — as, for example, by some peri-uterine inflammation produ- 
cing adhesions to the surrounding textures — much distress ensues, and 
if pregnancy supervenes more or less serious consequences may result. 
Generally speaking, the uterus may be said to lie in a line roughly 
corresponding with the axis of the pelvic brim, its fundus being 
pointed forward and its cervix lying in such a direction that a line 
drawn from it would inrpinge on the junction between the sacrum and 
coccyx. According to some authorities, the uterus in early life is more 
curved in the anterior direction, and is, in fact, normally in a state of 
anteflexion. Sappey holds that this is not necessarily the case, but 
that the amount of anterior curvature depends on the emptiness or 
fulness of the bladder, on which the uterus, as it were, moulds itself 
in the unimpregnated state. It is believed also that the body of the 



THE FEMALE GENERATIVE ORGANS. 



59 



uterus is very generally twisted somewhat obliquely, so that its anterior 
surface looks a little toward the right side, this probably depending 
on the presence and frequent distention of the rectum in the left side 
of the pelvis. The anterior surface of the uterus is convex, and is 
covered in three-fourths of its extent by the peritoneum which is inti- 
mately adherent to it. Below the reflection of the membrane it is 
loosely connected by cellular tissue to the bladder, so that any down- 
ward displacement of the uterus drags the bladder along with it. The 
posterior surface is also convex, but more distinctly so than the anterior, 
as may be observed in looking at a transverse section of the organ 
(Fig. 19). It is also covered by peritoneum, the reflection of which 
on the rectum forms the cavity known as Douglas's pouch. The 
fundus is the upper extremity of the uterus, lying above the points of 
entry of the Fallopian tubes. It is only slightly rounded in the 

Fig. 19. 




Transverse section of uterus. 
Fig. 20. 




Uterus and appendages in an infant. (After Farre.) 



virgin, but becomes more decidedly and permanently rounded in the 
woman who has borne children. 

Until the period of puberty the uterus remains small and unde- 
veloped (Fig. 20) ; after that time it reaches the adult size, at which it 



60 ORGANS CONCERNED IN PARTURITION. 

remains until menstruation ceases, when it again atrophies. If the 
woman has borne children, it always remains larger than in the 
nullipara. In the virgin adult the uterus measures 2J inches from 
the orifice to the fundus, rather more than half being taken up by the 
cervix. Its greatest breadth is opposite the iusertion of the Fallopian 
tubes; its greatest thickness, about 11 or 12 lines, opposite the centre 
of its body. Its average weight is about 9 or 10 drachms. Indepen- 
dently of pregnancy, the uterus is subject to great alterations of size 
toward the menstrual period, when, on account of the congestion then 
present, it enlarges — sometimes, it is said, considerably. This fact 
should be borne in mind, as this periodical swelling might be taken 
for an early pregnancy. 

For the purpose of description the uterus is conveniently divided into 
the fundus, with its rounded upper extremity, situated between the in- 
sertions of the Fallopian tubes ; the body, which is bounded above by 
the insertions of the Fallopian tubes, and below by the upper extremity 
of the cervix, and which is the part chiefly concerned in the reception 
and growth of the ovum ; and the cervix, which projects into the vagina, 
and dilates during labor to give passage to the child. The cervix is 
conical in shape, measuring 11 to 12 lines transversely at the base, 
and 6 or 7 in the antero-posterior direction ; while at the apex it 
measures 7 to 8 transversely, and 5 antero-posteriorly. It projects 
about 4 lines into the canal of the vagina, the remainder of the cervix 
being placed above the reflection of the vaginal mucous membrane. 
It varies much in form in the virgin and nulliparous married woman, 
and in the woman who has borne children ; and the differences are of 
importance in the diagnosis of pregnancy and uterine disease. In the 
virgin it is regularly pyramidal in shape. At its lower extremity is 
the opening of the external os uteri, forming a small circular opening, 
sometimes difficult to feel, and generally described as giving a sensa- 
tion to the examining finger like the extremity of the cartilage at the 
tip of the nose. It is bounded by two lips, the anterior of which is 
apparently larger on account of the position of the uterus. The sur- 
face of the cervix and the borders of the os are very smooth and 
regular. 

In women who have borne children these parts become considerably 
altered. The cervix is no longer conical, but is irregular in form and 
shortened. The lips of the os uteri become fissured and lobulated, on 
account of partial lacerations which have occurred during labor. The 
os is larger and more irregular in outline, and is sometimes sufficiently 
patulous to admit the tip of the finger. In old age the cervix atro- 
phies, and after the change of life it not uncommonly entirely dis- 
appears, so that the orifice of the os uteri is on a level with the roof 
of the vagina. 

The internal surface of the uterus comprises the cavities of the body 
and cervix — the former being rather less than the latter in length in 
virgins, but about equal in women who have borne children — separated 
from each other by a constriction forming the upper boundary of the 
cervical canal. The cavity of the body is triangular in shape, the base 
of the triangle being formed by a line joining the openings of the 



THE FEMALE GENERATIVE ORGANS 



61 



Fallopian tubes, its apex by the upper orifice of the cervix, or internal 
os, as it is sometimes called. In the virgin its boundaries are some- 
what convex, projecting inward. After childbearing they become 
straight or slightly concave. The opposing surfaces of the cavity are 
always in contact in the healthy state, or are only separated from each 
other by a small quantity of mucus. 

The cavity of the cervix is spindle-shaped or fusiform, narrower 
above and below, at the internal and external os uteri, and somewhat 
dilated between these two points. It is flattened from before back- 
ward, and its opposing surfaces also lie in contact, but not so closely 
as those of the body. On the mucous lining of the anterior and pos- 
terior surfaces is a prominent perpendicular ridge, with a lesser one at 
each side, from which transverse ridges proceed at more or less acute 
angles. They have received the name of the arbor vitce. According 
to Guyon, the perpendicular ridges are not exactly opposite, so that 
they fit into each other, and serve more completely to fill up the cavity 
of the cervix, especially toward the internal os (Fig. 21). The arbor 
vita? is most distinct in the virgin, and atrophies considerably after 
childbearino;. 



Fig. 21. 




Portion of interior of cervix. 



(Enlarged nine diameters.) 



(After Tyler Smith and Hassall.) 



The superior extremity of the cervical canal forms a narrow isthmus 
separating it from the cavity of the body, and measuring about three- 
eighths of an inch in diameter. Like the external os, it contracts after 
the cessation of menstruation, and in old age sometimes becomes en- 
tirely obliterated. 

The uterus is composed of three principal structures — the peritoneal, 
muscular, and mucous coats. The peritoneum forms an investment to 



62 



ORGANS CONCERNED IN PARTURITION. 



Fig. 22. 



the greater part of the organ, extending downward iu front to the 
level of the os internum, and behind to the top of the vagina, from which 
points it is reflected upward on the bladder and rectum respectively. 
At the sides the peritoneal investment is not so extensive, for a little 
below the level of the Fallopian tubes the peritoneal folds separate 
from each other, forming the broad ligaments (to be afterward de- 
scribed) ; here it is that the vessels and nerves supplying the uterus 
gain access to it. At the upper part of the organ the peritoneum is 
so closely adherent to the muscular tissue that it cannot be separated 
from it ; below the connection is more loose. The mass of the uterine 

tissue, both in the body and cer- 
vix, consists of unstriped muscu- 
lar fibres (Fig. 22), firmly united 
together by nucleated connective 
tissue and elastic fibres. The mus- 
cular fibre cells are large and fusi- 
form, with very attenuated extremi- 
ties, generally containing in their 
centre a distinct nucleus. These 
cells, as well as their nuclei, become 
greatly enlarged during pregnancy 
(Fig. 23) ; according to Strieker, 
this is only the case with the mus- 
cular fibres which play an important part in the expulsion of the 
foetus, those of the outermost and innermost layers not sharing in the 
increase of size. 1 In addition to these developed fibres there are, 
especially near the mucous coat, a number of round elementary cor- 
puscles, which are believed by Dr. Farre 2 to be the elementary form 
of the muscular fibres, and which he has traced in various intermediate 
states of development. Dr. John Williams 3 believes that a great part 




Muscular fibres of unimpregnated uterus 
o. Fibres united by connective tissue, b. 
Separate fibres and elementary corpuscles 
(After Farre.) 



Fig. 23. 




Developed muscular fibres from the gravid uterus. (After Wagner.) 

of the muscular tissue of the uterus, rather more indeed than three- 
fourths of its thickness, is an integral part of the mucous membrane, 
analogous to the muscularis mucosa? of the mucous membrane of the 
alimentary canal. This he describes as being separated from the rest 



1 Comparative Histology, vol. iii. ; Syd. Soc. Trans., p. 477. 

2 The Uterus and its Appendages, p. 632. 

3 "On the Structure of the Mucous Membrane of the Uterus," Obstet. Journ., 1875-6, vol. iii. v, 
496. 



THE FEMALE GENERATIVE ORGANS. 



63 



of the muscular tissue by a layer of rather loose connective tissue, 
containing numerous vessels. In early foetal life, and in the uteri of 
some of the lower animals, this appearance is very distinct; in the 
adult female uterus, however, it can be readily made out. 

On examining the uterine tissue in an unimpregnated condition, no 
definite arrangement of its muscular fibres can be made out, and the 
whole seemed blended in inextricable confusion. By observation of 
their relations when hypertrophied during pregnancy, Helie 1 has 
shown that they may, speaking roughly, be divided into three layers : 
an external ; a middle, chiefly longitudinal ; and an internal, chiefly 
circular. Into the details of their distribution, as described by him, 
it is needless to enter at length. Briefly, however, he describes the 
external layer as arising posteriorly at the junction of the body and 
cervix, and spreading upward and over the fundus. From this are 
derived the muscular fibres found in the broad and round ligaments, 
and more particularly described by Rouget. The middle layer is 
made up of strong fasciculi, which run upward, but decussate and 
unite with each other in a remarkable manner, so that those which 
are at first superficial become most deeply seated, and vice versa. The 
muscular fasciculi which form this coat curve in a circular manner 
round the large veins, so as to form a species of muscular canal 

FlG 24. 




From the body. From orifice of Fallopian tube. 
Lining membrane of uterus, showing network of capillaries and orifices of uterine glands. 

(After Farre.) 

through which they run. This arrangement is of peculiar importance, 
as it affords a satisfactory explanation of the mechanism by which 
hemorrhage after delivery is prevented. The internal layer is mainly 
composed of circular rings of muscular fibres, beginning around the 
openings of the Fallopian tubes, and forming wider and wider circles 
which eventually touch and interlace with each other. They surround 
the internal os, to which they form a kind of sphincter. In addition 
to these circular fibres on the internal uterine surface both anteriorly 
and posteriorlv, there is a well-marked triangular layer of longitudinal 
fibres, the base being above and the apex below, which sends muscular 
fasciculi into the mucous membrane. 

The anatomy of the lining membrane of the uterus has been the 
subject of considerable discussion. Its existence has been denied by 
many authorities, who maintain that it is in no sense a mucous mem- 
brane, but only a softened portion of true uterine tissue. It is, however, 



1 Recherches sur la Disposition des Fibres musculaires de l'Uterus. Paris, 1869. 



64 



ORGANS CONCERNED IN PARTURITION. 



pretty generally admitted by the best authorities that it is essentially 
a mucous membrane, differiug from others only in being more closely 
adherent to the subjacent structures, in consequence of not possessing 
any definite connective-tissue framework. 

It is a pale pink membrane of considerable thickness, most marked 
at the centre of the body, where it forms from one-eighth to one-fourth 
of the thickness of the whole uterine walls. At the internal os uteri 

it terminates by a distinct border, which 
fig. 25. separates it from the mucous membrane 

lining the cervical cavity. 

On the surface of the mucous membrane 
may be observed a multitude of little open- 
ings, about one-thirtieth of a line in width 
(Fig. 24). These are the orifices of the 
utricular glands, which are found in im- 
mense numbers all over the cavity of the 
uterus, and very closely agglomerated to- 
gether. They are little cul-de-sacs, nar- 
rower at their mouths than in their length, 
the blind extremities of which are found in 
the subjacent tissues (Fig. 26). Williams 
describes them as running obliquely toward 
the surface at the lower third of the cavity, 
perpendicularly at its middle, while toward 
the fundus they are at first perpendicular, 
and then oblique in their course (Fig. 25). 
By others they are described as being often 
twisted and corkscrew-like. One or more 
may unite to form a common orifice, several 
of which may open together in little pits or 
depressions on the surface of the mucous 
membrane. These glands are composed of 
structureless membrane lined with epithe- 
lium, the precise character of which is 
doubtful. By some it is described as co- 
lumnar, by others as tessellated, and by some 
again as ciliated. The most generally re- 
ceived opinion is that it is columnar, but not 
ciliated; therein differing from the epithe- 
lium covering the surface of the membrane, which is undoubtedly 
ciliated, the movements of the cilia being from within outward. 
Williams, however, has observed cilia in active movement on the 
columnar epithelium lining the glands, and also, states that at the 
deep-seated extremities of the glands, which penetrate between the 
muscular fibres for some distance, the columnar epithelium is replaced 
by rounded cells. The capillaries of the mucous membrane run down 
between the tubes, forming a lacework on their surfaces, and around 
their orifices. ' No true papillae exist in the membrane lining the 
uterine cavity. The mucous membrane of the uterus is peculiar in 
being always in a state of change and alteration, being thrown off at 




The course of the glands in the 
fully developed mucous mem- 
brane of the uterus, viz., just 
before the onset of a menstrual 
period. (After Williams.) 



THE FEMALE GENERATIVE ORGANS, 



65 



each menstrual period in the form of debris, and re-formed afresh by 
proliferation of the cells of the muscular and connective tissues, probably 
from below upward, the new membrane commencing at the internal os. 
Hence its appearance and structure vary considerably according to the 
time at which it is examined. The subject, however, will be more 
particularly studied in connection with menstruation. 

The mucous membrane of the cervix is much thicker and more 
transparent than that of the body of the uterus, from which it also 
differs in certain structural peculiarities. The general arrangements 
of its folds and surface have already been described. The lower half 
of the membrane lining the cavity of the cervix, and the whole of 
that covering its external or vaginal portion, are closely set with a 
large number of minute filiform, or clavate papillae (Fig. 27). Their 




Vertical section through the mucous membrane of the human uterus, e. Columnar epithelium ; 
the cilia are not represented, g g. Utricular glands, et ct. IntergLandular connective tissue, v v. 
Bloodvessels, m m. Muscularis mucosae. (After Tcrxer.) 



structure is similar to that of the mucous membrane itself, of which 
they seem to be merely elevations. They each contain a vascular loop 
(Fig. 28), and they are believed by Kilian and Farre to be mainly 
concerned in giving sensibility to this part of the generative tract. 
All over the interior of the cervix, both on the ridges of the mucous 
membrane and between their folds, are a very large number of mucous 
follicles consisting of a structureless membrane lined with cylindrical 
epithelium, and intimately united with connective tissue. They cease 
at the external orifice of the cervix, and they secrete the thick, tena- 

5 



6-3 



ORGANS CONCERNED IN PARTURITION, 



Fig. 27. 




Villi of os uteri stripped of epithelium. (After Tyler Smith and Hassall.) 



Fig. 28. 




Villi of uterus, covered with pavement epithelium and containing looped vessels. (After 
Tyler Smith and Hassall.) 



THE FEMALE GENERATIVE ORGANS. 



67 



cious, and alkaline mucus which is generally found filling the cervical 
cavity. The transparent follicles, known as the ovula Nabothii, 
which are sometimes found in considerable numbers in the cavity of 
the cervix, consist of mucous follicles the mouths of which have 
become obstructed, and their canals distended by mucous secretion. The 
lower third of the cervical canal, as well as the exterior of the cervix, 
is covered with pavement epithelium ; while on its upper portion is. 
found a columnar and ciliated epithelium similar to that lining the 
uterine cavity. 

Bandl 1 describes the cervical mucous membrane as extending much 
higher in the virgin than in women who have borne children, being 
traceable in the former nearly to the middle of the body of the uterus. 
During the first pregnancy he believes that the upper portion of the 
cervix is taken up into the body of the uterus, its mucous membrane 
never regaining the arrangement peculiar to that of the cervical canal. 

The arteries of the uterus are derived from the internal iliac and 
from the ovarian. They enter the uterus between the folds of the broad 
ligaments (Fig. 29), and, penetrating its muscular coat, anastomose 
freely with each other and with the corresponding vessels of the opposite 



Fig. 29. 



TUBAL VESSELS 



FALLOPIAN 




VAGINAL VENOUS PLEXUS 



UTERINE ARTERY 



V limp-SUPERIOR VAGINAL 

ARTERIES 



OS UTERI VAGINA CUT OPEN BEHIND 

Blood supply of uterus. (After Testut.) 



side. They are described by Williams 2 as entering the uterus on its 
sides and then running a somewhat superficial course, being separated 
from the peritoneum by a thin layer of muscular fibres. They are 
here placed in a distinct layer of connective tissue, and give off 
branches which pass perpendicularly toward the uterine canal. Their 
walls are thick and well developed, and they are remarkable for their 
verv tortuous course, forming spiral curves, especially in the upper 



i Arch. f. Gvnak., 1879, Ed. xiv., S. 237. 

2 Trans. Obst. Society, 1885, vol. xxvii. p. 112. 



68 



ORGANS CONCERNED IN PARTURITION. 



part of the uterus. They end in minute capillaries which form the 
fine meshes surrounding the glands, and in the cervix give off the 
loops entering the papilla?. Beneath the uterine mucous membrane 
these capillaries form a plexus, terminating in veins without valves, 
which unite with each other to form the large veins traversing the 
substance of the uterus, known during pregnancy as the uterine 
sinuses, the walls of which are closely adherent to the uterine tissues. 
These veins run a similar course to the arteries, and end in a venous 
plexus lying in the layer of connective tissue already mentioned, which 
Williams believes to be the true submucous tissue of the uterus, the 
thick layer of muscular tissue between it and the uterine cavity being 
really " muscularis niucosse." In consequence of this arrangement the 
circulation of the uterus can hardly be disturbed by mechanical causes. 
The veins, freely anastomosing with each other, pass from the uterus 
to the folds of the broad ligaments, where they unite to form, with the 
ovarian and vaginal veins, a large and well-developed venous network, 
known as the pampiniform plexus. 

The lymphatics of the uterus are large and well developed, and 
they play an important part in the production of certain puerperal dis- 
eases. A more minute knowledge than we at present possess of their 
course and distribution will probably throw much light on their influence 
in this respect. According to the researches of Leopold, 1 who has 
studied their minute anatomy carefully, they originate in lymph spaces 
between the fine bundles of connective tissue forming the basis of the 
mucous lining of the uterus. Here they are in intimate contact with 
the utricular glands and the ultimate ramifications of the uterine blood- 



FlG. 30. 




Lymphatics of the uterus. (After Poirier.) 



vessels. As they pass into the muscular tissue they become gradually 
narrowed into lymph-vessels and spaces, which have a very compli- 
cated arrangement, and which eventually unite together in the external 
muscular layer, especially on the sides of the uterus, to form large 



i Arch. f. Gynak., 1873, Bd. vi., Heft 1, S. 1. 



THE FEMALE GENERATIVE ORGANS. 



69 



canals which probably have valves. Immediately under the perito- 
neum these lymph-vessels form a large and characteristic network 
covering the anterior and posterior surfaces of the uterus, and present, 
in various parts of their course, large ampullae. They then spread 
over the Fallopian tubes. The lymphatics of the body of the uterus 
unite with the lumbar glands, those of the cervix with the pelvic 
glands. (Fig. 30.) 

The distribution and arrangement of the nerves of the uterus have 
been the subject of much controversy. They are derived mainly from 
the ovarian and hypogastric plexuses, inosculating freely with each other 
between the folds of the broad ligament, from which they enter the 
muscular tissue of the uterus, generally, but not invariably, following 
the course of the arteries. They are chiefly derived from the sympa- 
thetic ; but, as the hypogastric plexus is connected with the sacral 
nerves, it is probable that some fibres from the cerebro-spinal system 
are distributed to the cervix. It is now generally admitted that 
nervous filaments are distributed to the cervix, even as far as the 
external os, although their existence in this situation has been denied 
by Jobert and other writers. The ultimate distribution of the nerves 
is not yet made out. Polle describes a nerve filament as entering the 
papillae of the cervical mucous membrane along with the capillary 
loop, and Frankenhauser says the nerve fibres surround the muscles of 
the uterus in the form of plexuses, and terminate in the nuclei of the 
muscle cells. 

Anomalies of the Uterus. — Various abnormal conditions of the 
uterus and vagina are occasionally met with, which it is necessary to 



Fig. 81 




Bifid uterus. (After Farre.) 



mention, as they may have an important practical bearing on parturition 
The most frequent of these is the existence of a double, or partially 
double uterus (Fig. 31), similar to that found normally in many of 
the lower animals. This abnormality is explained by the development 
of the organ during foetal life. The uterus is formed out of struc- 
tures existing only in early foetal life, known as the Wolffian bodies. 
These consist of a number of tubes, situated on either side of the 
vertebral column, and opening externally into an excretory duct. 



70 ORGANS CONCERNED IN PARTURITION. 

Along their external border a hollow canal is formed, termed the canal 
of Miiller, which, like the excretory ducts, proceeds to the common 
cloaca of the digestive and urinary organs which then exists. The 
canal of Miiller unites with its fellow of the opposite side to form the 
uterus and Fallopian tubes in the female, and subsequently the central 
partition at their point of junction disappears. If, however, the pro- 
gress of development be in any way checked, the central partition may 
remain. Then we have produced either a complete double uterus or 
the uterus bicornis, which is bifid at its upper extremity only ; or a 
double vagina, each leading to a separate uterus. 

If pregnancy occur in any of these anomalous uteri, and many such 
cases are recorded, serious troubles may follow. It may happen that 
one horn of the double uterus is not sufficiently large to admit of preg- 
nancy going on to term, and rupture may occur. It is supposed that 
some cases, presumed to be tubal gestation, are really thus explicable. 
Impregnation may also occur in the two cornua at different times, 
leading to superfcetation. It is, however, quite possible that impreg- 
nation may occur in one horn of a bifid uterus, and labor be com- 
pleted without anything unusual being observed. A remarkable case 
of this sort has been recorded by Dr. Ross, of Brighton, 1 in which a 
patient miscarried of twins on July 16, 1870, and on October 31st, 
fifteen weeks later, she was delivered of a healthy child. Careful 
examination showed the existence of a complete double uterus, each 
side of which had been impregnated. Curiously enough, this patient had 
formerly given birth to six living children at term, nothing remark- 
able having been observed in her labors. It can only rarely happen 
that, under such circumstances, so favorable a result will follow, and 
more or less difficulty and danger may generally be expected. Occasion- 
ally the vagina only is double, the uterus being single. Dr. Matthews 
Duncan has recorded some cases of this kind, 2 in which the vaginal sep- 
tum formed an obstacle to the birth of the child, and required division. 

Lig-aments of the Uterus. — The various folds of peritoneum which 
invest the uterus serve to maintain it in position, and they are described 
as its ligaments. They are the broad, the vesico-uterine, and sacro- 
uterine ligaments ; the round ligaments are not peritoneal folds like 
the others. 

The broad lig-aments extend from either side of the uterus, where 
their laminae are separated from each other, transversely across to the 
pelvic wall, and thus divide the cavity of the pelvis into two parts ; 
the anterior containing the bladder, the posterior the rectum. Their 
upper borders are divided into three subsidiary folds, the anterior of 
which contains the round ligament, the middle the Fallopian tube, 
and the posterior the ovary. The arrangement has received the name 
of the ala vesper tilionis, from its fancied resemblance to a bat's wing. 
Between the folds of the broad ligaments are found the uterine vessels 
and nerves, and a certain amount of loose cellular tissue continuous 
with the pelvic fasciae. Here is situated that peculiar structure called 
the organ of Rosenmiiller, or the parovarium (Fig. 32), which is the 

i Lancet, 1871, vol. ii. p. 188. « Researches in Obstetrics, p. 443. 



THE FEMALE GENERATIVE ORGANS. 71 

remains of the Wolffian body, and corresponds to the epididymis in the 
male. This may best be seen in young subjects, by holding up the 
broad ligaments and looking through them by transmitted light ; but 
it exists at all ages. It consists of several tubes (eight or ten according 

Fig. 32. 




Adult paro\ arium, ovary, and Fallopian tube. (After Kobelt. 

to Farre, eighteen or twenty according to Bankes *), which are tortuous 
in their course. They are arranged in a pyramidal form, the base of 
the pyramid being toward the Fallopian tube, its apex being lost on 
the surface of the ovary. They are formed of fibrous tissue, and lined 
with pavement epithelium. They have no excretory duct or commu- 
nication with either the uterus or ovary, and their function, if they 
liave any, is unknown 

A number of muscular fibres are also found in this situation, lying 
between the meshes of the connective tissue. They have been particu- 
larly studied by Rouget, who describes them as interlacing with each 
•other, and forming an open network, continuous with the muscular 
tissues of the uterus (Fig. 33). They are divisible into two layers, the 
anterior of which is continuous with the muscular fibres of the anterior 
surface of the uterus, and goes to form part of the round ligament ; 
the posterior arises from the posterior wall of the uterus, and proceeds 
transversely outward, to become attached to the sacro-iliac synchon- 
drosis. A continuous muscular envelope is thus formed, which sur- 
rounds the whole of the uterus, Fallopian tubes, and ovaries. Its 
function is not yet thoroughly established. It is supposed to have the 
effect of retracting the stretched folds of peritoneum after deliverv, aud 
more especially of bringing the entire generative organs into harmoni- 
ous action during menstruation and the sexual orgasm ; in this way 
explaining, as we shall subsequently see, the rnechanisni by which the 
fimbriated extremity of the Fallopian tube is said to grasp the ovary 
prior to the rupture of a Graafian follicle. 

The round ligaments are essentially muscular in structure. Thev 
extend from the upper border of the uterus, with the fibres of which 

i Bankes ; On the Wolffian Bodies. 



72 



ORGANS CONCERNED IN PARTURITION, 



their muscular fibres are continuous, transversely, and then obliquely 
downward, until they reach the inguinal rings, where they blend with 
the cellular tissue. In the first part of their course the muscular 
fibres are solely of the unstriped variety, but soon they receive striped 
fibres from the transversalis muscles, and the columns of the inguinal 
ring, which surround and cover the unstriped muscular tissue. In 
addition to these structures they contain elastic and connective tissue, 
and arterial, venous, and nervous branches ; the former from the 
iliac or cremasteric arteries, the latter from the genito-crural nerve. 

Fig. 33. 




Posterior view of muscular and vascular arrangements. Vessels.— 1, 2, 3. Vaginal, cervical, and 
uterine plexuses. 4. Arteries of body of uterus. 5. Arteries supplying ovary. Muscular fasci- 
culi— -6, 7. Fibres attached to vagina, symphysis pubis, and sacro-iliac joint. 8. Muscular fasiculi 
from uterus and broad ligaments. 9, 10, 11, 12. Fasiculi attached to ovary and Fallopian tubes. 
(After Rouget.) 

According to Ranney, 1 the principal function of these ligaments is to 
draw the uterus toward the symphysis pubis during sexual intercourse, 
and thus to favor the ascent of the semen. 

The vesico -uterine ligaments are two folds of peritoneum pass- 
ing in front from the lower part of the body of the uterus to the fundus 
of the bladder. 

The utero-sacral ligaments consist of folds of peritoneum of a 
crescentic form, with their concavities looking inward; they start from 

1 Amer. Journ. Obstet., 1SS3, vol. xvi. p. 225. 



THE FEMALE GENERATIVE ORGANS. 73 

the lower part of the posterior surface of the uterus, aud curve back- 
ward to be attached to the third aud fourth sacral vertebrae. Within 
their folds exist bundles of muscular fibres, continuous with those of 
the uterus, as well as connective tissue, vessels, and nerves. The 
experiments of Savage, as well as of other anatomists, show that these 
ligaments have an important influence in preventing downward dis- 
placement of the womb. 

During pregnancy all these ligaments become greatly stretched and 
unfolded, rising out of the pelvic cavity and accommodating themselves 
to the increased size of the gravid uterus ; and they again contract to 
their natural size, possibly through the agency of the muscular fibres 
contained within them, after delivery has taken place. 

The Fallopian tubes, the homologues of the vasa deferentia in the 
male, are structures of great physiological interest. They serve the 
double purpose of conveying the semen to the ovary, and of carrying 
the ovule to the uterus. From the latter function they may be looked 
on as the excretory ducts of the ovaries ; but, unlike other excretory 
ducts, they are movable, so that they may apply themselves to the 
part of the ovaries from which the ovule is to come ; and so great is 
their mobility that there is reason to believe that a Fallopian tube 
may even grasp the ovary of the opposite side. Each tube proceeds 
from the upper angle of the uterus at first transversely outward, and 
then downward, backward, and inward, so as to reach the neighbor- 
hood of the ovary. In the first part of its course it is straight, after- 
ward it becomes flexuous and twisted on itself. It is contained in the 
upper part of the broad ligament, where it may be felt as a hard cord. 
It commences at the uterus by a narrow opening, admitting only the 
passage of a bristle, known as ostium uterinum. As it passes through 
the muscular walls of the uterus, the tube takes a somewhat curved 
course, and opens into the uterine cavity by a dilated aperture. From 
its uterine attachment the tube expands gradually until it terminates 
in its trumpet-shaped extremity ; just before its distal end, however, 
it again contracts slightly. The ovarian end of the tube is surrounded 
by a number of remarkable fringe-like processes. These consist of 
longitudinal membranous fimbriae, surrounding the aperture of the 
tube, like the tentacles of a polyp, varying considerably in number 
and size, and having their edges cut and subdivided. On their inner 
surface are found both transverse and longitudinal folds of mucous 
membrane, continuous with those lining the tube itself (Fig. 34). One 
of these fimbriae is always larger and more developed than the rest, 
and is indirectly united to the surface of the ovary by a fold of peri- 
toneum proceeding from its external surface. Its under surface is 
grooved so as to form a channel, open below. The function of this 
fringe-like structure, as has been supposed, is to grasp the ovary during 
the menstrual nisus ; and the fimbria which is attached to the ovary 
would seem to guide the tentacles to the ovary which they are intended 
to seize. It has never, however, been demonstrated that this grasping 
of the ovarv actually occurs. One or more supplementary series of 
fimbriae sometimes exist, which have an aperture of communication 
with the canal of the Fallopian tube, beyond its ovarian extremity, 



74 



ORGANS CONCERNED IN PARTURITION 



His has shown that the fimbriated extremity of the tube, after running 
over the upper part of the ovary, tarns down along its free border; 
so that its aperture lies below it, ready to receive the ovule when ex- 
pelled from the Graafian follicle. 1 



Fig. 34 




Fallopian tube laid open, a, b. Uterine portion of tube, c, d. Plicae of mucous mem- 
brane, e. Tubo-ovarian ligaments and fringes. /. Ovary, g. Round ligaments. (After 
Richard.) 

The tubes themselves consist of peritoneal, muscular, and mucous 
coats. The peritoneum surrounds the tube for three-fourths of its 
calibre, and comes into contact with the mucous lining at its fimbriated 
extremity, the only instance in the body where such a junction occurs. 
The muscular coat is principally composed of circular fibres, with a 
few longitudinal fibres interspersed. Its muscular character has been 
doubted, but Farre had no difficulty in demonstrating the existence of 
muscular fibres, both in the human female and many of the lower 
animals. According to Robin, the muscular tissue of the Fallopian 
tubes is entirely distinct from that of the uterus, from which he 
describes it as being separated by a distinct cellular septum. The 
mucous lining is thrown into a number of remarkable longitudinal 
folds, each of which contains a dense and vascular fibrous septum, with 
small muscular fibres, and is covered with a single layer of columnar 
and ciliated epithelium. The apposition of these produces a series of 
minute capillary tubes, along which the ovules are propelled, the action 
of the cilia, which is toward the uterus, apparently favoring their 
progress. 

The ovaries are the bodies in which the ovules are formed, and 
from which they are expelled, and the changes going on in them in 
connection with the process of ovulation, during the whole period 
between the establishment of puberty and the cessation of menstruation, 
have an enormous influence on the female economy. Normally, the 

1 His: Archiv f. anat. uud Phys. 1881. 



THE FEMALE GENERATIVE ORGANS. 75 

ovaries are two in number ; in some exceptional cases a supplementary 
ovary has been discovered ; or they may be entirely absent. They 
are placed in the posterior folds of the broad ligaments, usually below 
the brim of the pelvis, behind the Fallopian tubes, the left in front of 
the rectum, the right in front of some coils of the small intestine. 
Their situation varies, however, very much under different circum- 
stances, so that they can scarcely be said to have a fixed and normal 
position ; most probably, however, they are normally placed close 
below the brim of the pelvis, with their long diameters almost vertical, 
and immediately above the aperture of the distal extremity of the 
Fallopian tubes. In pregnancy they rise into the abdominal cavity 
with the enlarging uterus; and in certain conditions they are dislo- 
cated downward into Douglas's space, where they may be felt through 
the vagina as rounded and very tender bodies. 

The folds of the broad ligament form for them a kind of loose 
mesentery. Each of them is united to the upper angle of the uterus 
by a special ligament called the utero-ovariau. This is a rounded 
band of organic muscular fibres, about an inch in length, continuous 
with the superficial muscular fibres of the posterior wall of the uterus, 
and attached to the inner extremity of the ovary. It is surrounded 
by peritoneum, and through it the muscular fibres, which form an 
important integral part in the structure of the ovaries, are conveyed to 
them. The ovary is also attached to the fimbriated extremity of the 
Fallopian tube in the manner already described. 

The ovary is of an irregular oval shape (Fig. 35), the upper border 
being convex, the lower — through which the vessels and nerves enter 
— being straight. The anterior surface, like that of the uterus, is less 
convex than the posterior. The outer extremity is more rounded and 
bulbous than the inner, which is somewhat pointed and eventually lost 
in its proper ligament. By these peculiarities it is possible to dis- 
tinguish the left from the right ovary, after they have been removed 
from the body. The ovary varies much in size under different cir- 
cumstances. On an average, in adult life it measures from one to two 
inches in length, three-quarters of an inch in width, and about half 
an inch in thickness. It increases greatly in size during each men- 
strual period — a fact which has been demonstrated in certain cases of 
ovarian hernia, in which the protruded ovary has been seen to swell 
as menstruation commenced ; also during pregnancy, when it is said 
to be double its usual size. After the change of life it atrophies, and 
becomes rough and wrinked on its surface. Before puberty, the sur- 
face of the ovary is smooth and polished, and of a whitish color. 
After menstruation commences, its surface becomes scarred by the 
rupture of the Graafian follicles (Fig. 35, a a a), each of which leaves a 
little linear or striated cicatrix, of a brownish color ; and the older the 
patient the greater are the number of these cicatrices. 

The structure of the ovary lias been made the subject of many 
important observations. It has an external covering of epithelium, 
originally continuous with the peritoneum, called by some the germ- 
epithelium, in consequence of the ovules being formed from it in early 
foatal life. In the adult it is separated from the peritoneum at the 



76 



ORGANS CONCERNED IN PARTURITION 



base of the organ by a circular white line, and it consists of columnar 
epithelium, differing only from the epithelium lining the Fallopian 
tubes, with which it is sometimes continuous through the attached 
fimbria uniting the tube and the ovary, in being destitute of cilia. 
Immediately beneath this covering is the dense coat known as the 
tunica albuginea, on account of its whitish color. It consists of short 
connective-tissue fibres, arranged in laminae, among which are inter- 
spersed fusiform muscular fibres. At the point where the vessels and 
nerves enter the ovary this membrane is raised into a ridge, which is 
continuous with the utero-ovarian ligament, and is called the hilum. 
The tunica albuginea is so intimately blended with the stroma of the 
ovary as to be inseparable on dissection ; it does not, therefore, exist 
as a distinct lamina, but is merely the external part of the proper 
structure of the ovary, in which more dense connective tissue is devel- 
oped than elsewhere. 

On making a longitudinal section of the ovary (Fig. 36), it will be 
seen to be composed of two parts, the more internal of which is of a 
reddish color from the number of vessels that ramify in it, and is 
called the medullary or vascular zone ; while the external, of a whitish 




A A Ovary enlarged under menstrual nisus. b. Ripe follicle projecting en Its surface. 
aaa Traces of previously ruptured follicles. 

tint, receives the name of the cortical or parenchymatous substance. 
The former consists of loose connective tissue interspersed with elastic, 
and a considerable number of muscular fibres. According to Rouget 1 
and His 2 the muscular structure forms the greater part of the ovarian 
stroma. The latter describes it as consisting essentially of interwoven 
muscular fibres, which he terms the " fusiform tissue, " and which he 
believes to be continuous with the muscular layers of the ovarian vessels. 
The former believes that the muscular fasciculi accompany the vessels 
in the form of sheaths, as in erectile tissues. Both attribute to the 
muscular tissues an important influence in the expulsion of the ovules, 



i Journal de Physiol., i. p. 737. 



2 Schultze's Arch. f. mikroscop. Anat., 1S65. 



THE FEMALE GENERATIVE ORGANS. 



77 



and in the rapture of the Graafian follicles. 
Waldeyer and other writers, however, do 
not consider it to be so exteusively developed 
as Rouget and His believe. The cortical 
substance is the more important, as that in 
which the Graafian follicles and ovules are 
formed. It consists of interlaced fibres of 
connective tissue, containing a large number 
of nuclei. The muscular fibres of the med- 
ullary substance do not seem to penetrate 
into it in the human female. In it are found 
the Graafian follicles, which exist in enor- 
mous numbers from the earliest periods of life, and in all stages of 
development (Fig 37). 




Longitudinal section of adult 
ovary. (After Farre.) 



Fig. 37. 




Section through the cortical part of the ovary, e. Surface epithelium, ss. Ovarian stroma. 
1 1. Large-sized Graafian rollicles. 2 2. Middle-sized ; and 3 3. Small-sized Graafian follicles. 
o Ovule within Graafian follicle, v v. Bloodvessels in the stroma, g. Cells of the membrana gran- 
ulosa. (After Turner.) 

The Graafian Follicles. — According to the researches of Pfluger, 
Waldeyer, and other German writers, the Graafian follicles are formed 
in early foetal life by cylindrical inflections of the epithelial covering 
of the ovary, which dip into the substance of the gland. These tubular 
filaments anastomose with each other, and in them are formed the 
ovules, which are originally the epithelial cells lining the tubes. Por- 
tions become shut off from the rest of the filaments, and form the 
Graafian follicles. The ovules, on this view, are highly developed 
epithelial cells, originally derived from the surface of the ovary, and 
not developed in its stroma. These tubular filaments disappear shortly 
after birth, but they have recently been detected by Slavyansky 1 in 



i Annales de Gynec. Feb. 1871. 



78 ORGANS CONCERNED IN PARTURITION. 

the ovaries of a woman thirty years of age. These observations have 
been modified by Dr. Foulis. 1 He recognizes the origin of the ovules 
from the germ-epithelium covering the surface of the ovary, which is 
itself derived from the Wolffian body. He believes all the ovules to 

Fig. 38. 




Vertical section through the ovary of the human foetus, g g. Germ-epithelium, with o o. Develop- 
ing ovules in it. s s. Ovarian stroma containing c c c. Fusiform connective-tissue corpuscles, 
v v. Capillary bloodvessels. In the centre of the figure an involution of the germ-epithelium is 
shown; and at the left lower side a primordial ovule, with the connective-tissue corpuscles 
ranging themselves round it. (After Foulis.) 

be formed from the germ-epithelium corpuscles. Some of these, which 
are differentiated from the rest by their greater size, rounded shape, 
and large nuclei, become imbedded in the stroma of the ovary by the 
outgrowth of processes of vascular connective tissue, fresh germ- 
epithelial corpuscles being constantly produced on the surface of the 
organ up to the age of two and a half years, to take the place of those 
already imbedded in its stroma. He believes the Graafian follicles to 
be formed by the growth of delicate processes of connective tissue 
between and around the ovules, but not from tubular inflections of the 
epithelium covering the gland, as described by Waldeyer (Fig. 38). 
This view is supported by the researches of Balfour, 2 who arrives at 
the conclusion that the whole egg-containing part of the ovary is really 
the thickened germinal epithelium, hroken up into a kind of mesh- 
work by growths of vascular stroma. According to this theory, 
PA tiger's tubular filaments are merely trabecule of germinal epithe- 
lium, modified cells of which become developed into ovules. 

The greater proportion of the Graafian follicles are only visible with 
the high powers of the microscope, but those which are approaching 
maturity are distinctly to be seen by the naked eye. The quantity of 
these follicles is immense. Foulis estimates that at birth each human 
ovary contains^ not less than 30,000. No fresh follicles appear to be 
formed after birth, and as development goes on, only some grow, and 
by pressure on the others, destroy them. Of those that grow, of course 
only a few ever reach maturity ; they are scattered through the sub- 

i Proceedings of the Royal Soc. of Edinh., April, 1885, and Journ. of Anat. and Phys., vol xiii 1879 
2 F. M. Balfour: " Structure and Development of Vertebrate Ovary." Quarterly Journal of 
Microscopical Science, vol. xviii., 1878. 



THE FEMALE GENERATIVE ORGANS. 



79 



stance of the ovary, those that are more deeply seated being generally 
larger than those near the surface, some developing in the stroma, 
others on the surface of the organ, where they eventually burst, and 
are discharged into the Fallopian tube. 

A ripe Graafian follicle has an external investing membrane (Fig. 
39), which is generally described as consisting of two distinct layers : 
the external, or tunica fibrosa, 




Diagrammatic section of Graafian follicle. 1. 
Ovum. 2. Membrana granulosa. 3. External 
membrane of Graafian follicle. 4. Its vessels. 5. 
Ovarian stroma. 6. Cavity of Graafian follicle. 
7. External covering of ovary. 



highly vascular, and formed of FlG - "■ 

connective tissue ; the internal, 
or tunica propria, composed of 
young connective tissue, con- 
taining a large number of fusi- 
form or stellate cells, and form- 
ing a basement membrane to the 
epithelial layer which lies inter- 
nal to it. These layers, however, 
appear to be essentially formed 
of condensed ovarian stroma. 
Within this capsule is the epithe- 
lial lining called the membrana 
granulosa, consisting of colum- 
nar epithelial cells, which, 
according to Foulis, are origi- 
nally formed from the nuclei of 
the fibro-nuclear tissue of the 
stroma of the ovary, but which, according to Waldeyer and Balfour, 
are formed from the germinal epithelium itself. At one part of the 
circumference of the ovisac is situated the ovule, around which 
the epithelial cells are congregated in greater quantity, constituting 
the projection known as the discus proligerus. The remainder of the 
cavity of the follicle is filled with a small quantity of transparent 
fluid, the liquor folliculi, traversed by three or four minute bands, the 
retinacula of Barry, which are attached to the opposite walls of the 
follicular cavity, and apparently serve the purpose of suspending 
the ovule and maintaining it in a proper position. In many young 
follicles this cavity does not at first exist, the follicle being entirely 
filled by the ovule. According to Waldeyer, the liquor folliculi is 
formed by the disintegration of the epithelial cells, the fluid thus 
produced collecting, and distending the interior of the follicle. 

The Ovule. — The ovule is attached to some part of the internal 
surface of the Graafian follicle. It is a rounded vesicle about T -^- 
of an inch in diameter, and is surrounded by a layer of columnar cells, 
distinct from those of the discus proligerus, in which it lies. It is 
invested by a transparent elastic membrane, the zona radiata, or vitel- 
line membrane. In most of the lower animals the zona radiata is 
perforated bv numerous very minute pores, only visible under the 
highest powers of the microscope ; in others there is a distinct aperture 
of a larger size, the micropyle, allowing the passage of the spermatozoa 
into the interior of the ovule. It is possible that similar apertures may 
exist in the human ovule, but they have not been demonstrated. 



80 ORGANS CONCERNED IN PARTURITION. 

Within the zona radiata some embryologists describe a second fine 
membrane, the existence of which has been denied by Bischoff. The 
cavity of the ovule is filled with a viscid yellow fluid, the yelk, con- 
taining; numerous granules. It entirely fills the cavity, to the walls of 
which it is non-adherent. It consists of primitive cell matter, called 
the protoplasm of the yelk, from which the embryo is developed, and 
of the granules, called the deutoplasm, which furnish the nutritive 
material for cell growth. In the centre of the yelk in young, and at 
some portion of the periphery in mature ovules, is situated the germinal 
vesicle, which is a clear circular vesicle, refracting light strongly, and 
about 3-J-g- of an inch in diameter. It contains a few granules, and a 
nucleolus, or germinal spot, which is sometimes double. 

Fig. 40. 




Bulb of ovary, u. Uterus, o. Ovary and utero-ovarian ligament, t. Fallopian tube. 1. Utero- 
ovarian vein. 2. Pampiniform ovarian plexus. 3. Commencement of spermatic vein. 

From within outward, therefore, we find — 

1 . The germinal spot ; round this 

2. The germinal vesicle contained in 

3. The yelk, which is surrounded by the 

4. Zona radiata, with its layers of columnar epithelial cells. 

These constitute the ovule. 

The ovule is contained in — 

The Graafian follicle, and lies in that part of its epithelial lining 
called the — 

JJiscus proligerus, the rest of the follicle being occupied by the liquor 
folliculi. Round these we have the epithelial lining or membrana gran- 
ulosa, and the external coat, consisting of the tunica propria and the 
tunica fibrosa. 

The vascular supply of the ovary is complex. The arteries enter at 
the liilum, penetrating the stroma in a spiral curve, and are ultimately 
distributed in a rich capillary plexus to the follicles. The large veins 
unite freely with each other, and form a vascular and erectile plexus, 
continuous with that surrounding the uterus, called the bulb of the 



THE FEMALE GENERATIVE ORGANS 



81 



ovary (Fig. 40). Lymphatics and nerves exist, but their mode of 
termination is unknown. 

The Mammary Glands. — To complete the consideration of the 
generative organs of the female, we must study the mammary glands, 
which secrete the fluid destined to nourish the child. In the human 
subject they are two in number, and instead of being placed upon the 
abdomen, as in most animals, they are 
situated on either side of the sternum, fig. a. 

over the pectorales majores muscles, and 
extend from the third to the sixth ribs. 
This position of the glands is obviously 
intended to suit the erect position of the 
female in suckling. They are convex 
anteriorly, and flattened posteriorly where 
they rest on the muscles. They vary 
greatly in size in different subjects, chiefly 
in proportion to the amount of adipose 
tissue they contain. In man, and in girls 
previous to puberty, they are rudimentary 
in structure; while in pregnant women 
they increase greatly in size, the true glan- 
dular structures becoming much hypertro- 
phied. Anomalies in shape and position 
are sometimes observed. Supplementary 
mammae, one or more in number, situated 
on the upper portion of the mammae are 
sometimes met with, identical in structure 
with the normally situated glands ; or, 
more commonly, an extra nipple is observed by the side of the normal 
one. In some races, especially the African, the mamnise are so enor- 
mously developed that the mother is able to suckle her child over her 
shoulder. 

The skin covering the gland is soft and supple, and during preg- 
nancy often becomes covered with fine white lines, while large blue 
veins may be observed coursing over. Underneath it is a quantity of 
connective tissue, containing a considerable amount of fat, which ex- 
tends between the true glandular structure. This is composed of from 
fifteen to twenty lobes, each of which is formed of a number of lobules. 
The lobules are produced by the aggregation of the terminal acini in 
which the milk is formed. The acini are minute cul-de-sacs opening 
into little ductSj which unite with each other until they form a large 
duct for each lobule ; the ducts of each lobule unite with each other, 
until they end in a still larger duct common to each of the fifteen or 
twenty lobes into which the gland is divided, and eventually open on 
the surface of the nipple. These terminal canals are known as the 
galactophorous ducts (Fig. 41). They become widely dilated as they 
approach the nipple, so as to form reservoirs in which milk is stored 
until it is required, but when they actually enter the nipple they again 
contract. Sometimes they give off lateral branches, but, according to 
Sappey, they do not anastomose with each other, as some anatomists 




1. Galactophorous ducts. 2. Lobuli 
of the mammary gland. 



84 ORGANS CONCERNED IN PARTURITION. 

come near the surface of the ovary. Amongst these one becomes espe- 
cially developed, preparatory to rupture, and upon it for the time beiug 
all the vital energy of the ovary seems to be concentrated. A similar 
change in one, sometimes in more than one, follicle takes place periodi- 
cally during the whole of the childbearing epoch, and an examination of 
the ovary will show several follicles in different stages of development. 
The maturing follicle becomes gradually larger, until it forms a pro- 
jection on the surface of the ovary, from five to seven lines in breadth, 
but sometimes even as large as a nut (Fig. 35). This growth is due 
to the distention of the follicle by the increase of its contained fluid, 
which causes it so to press upon the ovarian structures covering it that 
they become thinned, separated from each other, and. partially absorbed, 
until they eventually readily lacerate. The follicle also becomes greatly 
congested, the capillaries coursing over it become increased in size and 
loaded with blood, and being seen through the attenuated ovarian 
tissue, give it, when mature, a bright-red. color. At this time some 
of these distended capillaries in its inner coat lacerate, and a certain 
quantity of blood escapes into its cavity. This escape of blood takes 
place before rupture, and seems to have for its principal object the 
increase of the tension of the follicle, of which it has been termed the 
menstruation. Pouchet was of opinion that the blood collects behind 
the ovule, and carries it up to the surface of the follicle. 

2. Escape of the ovule. By these means the follicle is more and 
more distended, until at last it ruptures (Plate II., Fig. 1), either 
spontaneously, or, it may be, under the stimulus of sexual excitement. 
Whether the laceration takes place during, before, or after the men- 
strual discharge is not yet positively known ; from the results of post- 
mortem examination in a number of women who died shortly before 
or after the period, Williams believes that the ovules are expelled 
before the monthly flow commences. 1 In order that the ovule may 
escape, the laceration must, of course, involve not only the coats of the 
Graafian follicles, but also the superincumbent structures. 

Laceration seems to be aided by the growth of the internal layer of 
the follicle, which increases in thickness before rupture, and assumes a 
characteristic yellow color from the number of oil-globules it then 
contains. It is also greatly facilitated, if it be not actually produced, 
by the turgescence of the ovary at each menstrual period, and by the 
contraction of the muscular fibres in the ovarian stroma. As soon as 
the rent in the follicular walls is produced, the ovule is discharged, 
surrounded by some of the cells of the membrana granulosa, and is 
received into the fimbriated extremity of the Fallopian tube, which 
has been said to grasp the ovary over the site of the rupture. This, 
however, has never been satisfactorily proved to be the case. Henle 
supposed that the ovum is washed into the open extremity of the 
Fallopian tube, by means of currents produced in the peritoneal serum 
by the vibration of the cilise of the epithelium which covers both 
surfaces of the fimbriae. By the vibratile cilise of its epithelial lining 
it is then conducted into the canal of the tube, along which it is pro- 

1 Proceedings of the Royal Society. 1875. 



PLATE IT. 



Fig. 1 



Fig. 2. 





A recently ruptured and bloody Graafian 

follicle, just developing into 

a Corpus luteum. 



Corpus luteum ten days after 
menstruation. 



Fig. 3. 



Fig. 4. 









^K.4 W^ 



Degenerated Graafian follicle which has 

never ruptured. 
{The "false corpus luteum of Da Hon.") 



Corpus luteum of Pregnancy 



Illustrations of the Corpus Luteum. (After Dalton.) 



OVULATION AND MENSTRUATION. 



85 



Fig. 42. 



pelled, partly by ciliary action, arid partly by muscular contraction in 
the walls of the tube. 

After the ovule has escaped, certain characteristic changes occur in 
the empty Graafian follicle, which have for their object its cicatrization 
and obliteration. There are great differences in the changes which 
occur when impregnation has followed the escape of the ovule, and 
they are then so remarkable that they have been considered certain 
signs of pregnancy. They are, however, differences of degree rather 
than of kind. It will be well, however, to discuss them separately. 

As soon as the ovule is discharged, the edges of the rent through 
which it has escaped become agglutinated by exudation, and the follicle 
shrinks, as is generally believed, by the inherent elasticity of its in- 
ternal coat but according to Robin, who denies the existence of this 
coat, from compression by the muscular fibres of the ovarian stroma. 
In proportion to the contraction that takes place, the inner layer of 
the follicle, the cells of Ayhich have become greatly hypertrophied and 
loaded with fat-granules previous to rupture, is thrown into numerous 
folds (Plate II., Fig. 2). Between these, young connective tissue 
begins to form, and vascular offshoots, 
like papillae, arising from the vascular 
network surrounding the follicles, also 
penetrate the interstices. The greater 
the amount of contraction the deeper 
these folds become, giving to a section of 
the follicle an appearance similar to that 
of the convolutions of the brain (Fig. 42). 
These folds in the human subject are 
generally of a bright-yellow color, but 
in some of the mammalia they are of a 
deep red. The tint was formerly ascribed 
by Raciborski to absorption of the color- 
ing matter of the blood-clot contained in 
the follicular cavity, a theory he has 
more recently abandoned in favor of the 
view maintained by Coste, that it is due 
to the inherent color of the cells of the 
lining membrane of the follicle, which, though not well marked in a 
single cell, becomes very apparent en masse. The existence of a con- 
tained blood-clot is also denied by the latter physiologist, except as 
an unusual pathological condition ; and he describes the cavity as 
containing a gelatinous and plastic fluid, which becomes absorbed as 
contraction advances. The more recent researches of Dalton, 1 how- 
ever, show the existence of a central blood-clot in the cavity of the 
follicle, and he considers its occasional absence to be connected with 
disturbance or cessation of the menstrual function. The folds into 
which the membrane has been thrown continue to increase in size, 
from the proliferation of their cells, until they unite and become 
adherent, and eventually fill the follicular cavity. By the time that 




Section of ovary, showing corpus 
luteum three weeks after menstrua- 
tion. (After Dalton.) 



1 " Report on the Corpus Luteum," American Gynec. Trans., LS77, vol. ii. p. 111. 



86 ORGANS CONCERNED IN PARTURITION. 

another Graafian follicle is matured and ready for rupture, the dimi- 
nution lias advanced considerably, and the empty ovisac is reduced to 
a very small size. The cavity is now nearly obliterated, the yellow 
color of the convolutions is altered into a whitish tint, and on section 
the corpus luteum has the appearance of a compact white stellate 
cicatrix, which generally disappears in less than forty days from the 
period of rupture. The tissue of the ovary at the site of laceration 
also shrinks, and this, aided by the contraction of the follicle, gives 
rise to one of those permanent pits or depressions which mark the 
surface of the adult ovary. Slavyansky 1 has shown that only a few 
of the immense number of Graafian follicles undergo these alterations. 
The greater proportion of them seem never to discharge their ovules, 
but, after increasing in size, undergo retrogressive changes exactly 
similar in their nature, but to a much less extent, to those which 
result in the formation of a corpus luteum. The sites of these may 
afterward be seen as minute striae in the substance of the ovary. 

Should pregnancy occur, all the changes above described take place ; 
but, inasmuch as the ovary partakes of the stimulus to which all the 
generative organs are then subjected, they are much more marked and 
apparent (Plate II., Fig. 4). Instead of contracting and disappear- 
ing in a few weeks, the corpus luteum continues to grow until the third 
or fourth month of pregnancy ; the folds of the inner layer of the 
ovisac become large and fleshy, and permeated by numerous capillaries, 
and ultimately become so firmly united that the margins of the con- 
volutions thin and disappear, leaving only a firm fleshy yellow mass, 
averaging from 1 to 1J inches in thickness, which surrounds a central 
cavity, often containing a whitish fibrillated structure, believed to be 
the remains of a central blood-clot. This was erroneously supposed 
by Montgomery to be the inner layer of the follicle itself, and he con- 
ceived the yellow substance to be a new formation between it and the 
external layer; while Robert Lee thought it was placed external to 
both the external and internal layers. 

Between the third and fourth months of pregnancy, when the corpus 
luteum has attained its maximum of development (Fig. 43), it forms a 
firm projection on the surface of the ovary, averaging about one inch 
in length and rather more than half an inch in breadth. After this it 
commences to atrophy (Fig. 44), the fat-cells become absorbed, and the 
capillaries disappear. Cicatrization is not complete until from one to 
two months after delivery. 

On account of the marked appearance of the corpus luteum, it was 
formerly considered to be an infallible sign of pregnancy ; and it was 
distinguished from the corpus luteum of the non-pregnant state by 
being called a " true " as opposed to a " false " corpus luteum. From 
what has been said it will be obvious that this designation is essentially 
wrong, as the difference is one of degree only. Dalton 2 applies the 
term '* false corpus luteum " to a degenerated condition sometimes met 
with in an unruptured Graafian follicle consisting in reabsorption of 
its contents and thickening of its walls (Plate II., Fig. 3). It differs 

1 Archiv de Phys., March, 1874. 2 op. cit., p. 64. 



OVULATION AND MENSTRUATION. 



87 



from the "true" corpus luteuni in being deeply seated in the substance 
of the ovary j in having no central clot, and in being unconnected with 
a cicatrix on the surface of the ovary. Nor do obstetricians attach by 
any means the same importance as they did formerly to the presence of 
the corpus luteum as indicating impregnation; for even when well 
marked, other and more reliable signs of recent delivery, such as 
enlargement of the uterus, are sure to be present, especially at the time 
when the corpus luteum has reached its maximum of development ; 
while after delivery at term it has no longer a sufficiently characteristic 
appearance to be depended on. 



Fig. 43. 



Fig. 44. 





Corpus luteum of the fourth month of pregnancy 
(After Dalton.) 



Corpus luteum of pregnancy at 
term. (After Dalton.) 



Menstruation. — By the term menstruation (catamenia, periods, etc.) 
is meant the periodical discharge of blood from the uterus which 
occurs, in the healthy woman, every lunar month, except during preg- 
nancy and lactation, when it is, as a rule, suspended. ^ 

The first appearance of menstruation coincides with the establish- 
ment of puberty, and the physical changes that accompany it indicate 
that the female is capable of conception and childbearing, although 
exceptional cases are recorded in which pregnancy occurred before 
menstruation had begun. In the temperate climates it generally com- 
mences between the fourteenth and sixteenth years, the largest number 
of cases being met with in the fifteenth year. This rule is subject to 
many exceptions, it being by no means very rare for menstruation to 
become established as early as the tenth or eleventh year, or to be 
delayed until the eighteenth or twentieth. Beyond these physiological 
limits a few cases are from time to time met with in which it has begun 
in early infancv, or not until a comparatively late period of life. 

Influence of Climate, Race, etc. — Various accidental circumstances 
have much to do with its establishment. As a rule it occurs somewhat 
earlier in tropical, and later in very cold than in temperate climates. 
The influence of climate has been unduly exaggerated. It used to be 
generally stated that in the Arctic regions women did not menstruate 
until they were of mature age., and that in the tropics girls of ten or 



88 ORGANS CONCERNED IN PARTURITION. 

twelve years of age did so habitually. The researches of Robertson, 
of Manchester, 1 first showed that the generally received opinions were 
erroneous; and the collection of a large number of statistics has cor- 
roborated his opinion. There can be no doubt, however, that a larger 
proportion of girls menstruate early in warm climates. Joulin found 
that in tropical climates, out of 1635 cases, the largest proportion began 
to menstruate between the twelfth and thirteenth years ; so that there 
is an average difference of more than two years befoveen the period of 
its establishment in the tropics and in temperate countries. Harris 2 
states that among the Hindoos 1 to 2 per cent, menstruate as early as 
nine years of age ; 3 to 4 per cent, at ten ; 8 per cent, at eleven ; and 
25 per cent, at twelve ; while in London or Paris probably not more 
than one girl in 1000 or 1200 does so at nine years. The converse 
holds true with regard to cold climates, although we are not in pos- 
session of a sufficient number of accurate statistics to draw very reliable 
conclusions on this point ; but out of 4715 cases, including returns from 
Denmark, Norway and Sweden, Russia, and Labrador," it was found 
that menstruation was established on an average a year later than in 
more temperate countries. It is probable that the mere influence of 
temperature has much to do in producing these differences, but there are 
other factors, the action of which must not be overlooked. Raciborski 
attributes considerable importance to the effect of race; and he has 
quoted Dr. Webb, of Calcutta, to the effect that English girls in India, 
although subjected to the same climatic influence as the Indian races, 
do not, as a rule, menstruate earlier than in England ; while, in Austria, 
girls of the Magyar race menstruate considerably later than those of 
German parentage. 3 The surroundings of girls, and their manner of 
education and living, have probably also a marked influence in pro- 
moting or retarding its establishment. Thus, it will commence earlier 
in the children of the rich, who are likely to have a highly developed 
nervous organization, and are habituated to luxurious living, and a 
premature stimulation of the mental faculties by novel-reading, society, 
and the like ; while amongst the hard-worked poor, or in girls brought 
up in the country, it is more likely to begin later. Premature sexual 
excitement is said also to favor its early appearance, and the influence 
of this among the factory girls of Manchester, who are exposed in the 
course of their work to the temptations arising from the promiscuous 
mixing of the sexes, has been pointed out by Dr. Clay. 4 

Changes Occurring' at Puberty. — The first appearance of men- 
struation is accompanied by certain well-marked changes in the female 
system, on the occurrence of w r hich we say that the girl has arrived at 
the period of puberty. The pubes become' covered with hair, the 
breasts enlarge, the pelvis assumes its fully developed form, and the 
general contour of the body fills out. The mental qualities also alter ; 
the girl becomes more shy and retiring, and her whole bearing indi- 
cates the change that has taken place. The menstrual discharge is not 
established regularly at once. For one or two months there may be 

* Edin. Med. and Surg. Journ., 1832. 

2 Araer. Journ. of Obstet., 1870-71. vol. iii. p. 611. R. P. Harris " On Early Puberty." 

8 Op. cit., p. 227. 4 Brit. Record of Obstet. Med., voi. i. 



OVULATION AND MENSTRUATION. 89 

only premonitory symptoms — a vague sense of discomfort, pains in 
the breasts, and a feeling of weight and heat in the back and loins. 
There then may be a discharge of mucus tinged with blood, or of 
pure blood, and this may not again show itself for several months. 
Such irregularities are of little consequence on the first establishment 
of the function, and need give rise to no apprehension. 

Duration. — As a rule, the discharge recurs every twentv-eight days, 
and with some women with such regularity that they can foretell its 
appearance almost to the hour. The rule is, however, subject to very, 
great variations. It is by no means uncommon, and strictly within 
the limits of health, for it to appear every twentieth day, or even with 
less interval ; while in other cases as much as six weeks may habitu- 
ally intervene between two periods. The period of recurrence may 
also vary in the same subject. I am acquainted with patients who 
sometimes only have twenty-eight days, at others as many as forty- 
eight days, between their periods, without their health in any way 
suffering. Joulin mentions the case of a lady who only menstruated 
two or three times in the year, and whose sister had the same pecu- 
liarity. 

The duration of the period varies in different women, and in the 
same woman at different times. In this country its average is four or 
five days, while in France, Dubois and Brierre de Boismont fix eight 
days as the most usual length. Some women are only unwell for a 
few hours, while in others the period may last many days beyond the 
average without being considered abnormal. 

The quantity of blood lost varies in different women. Hippocrates 
puts it at 5 xvn j> which, however, is much too high an estimate. 
Arthur Farre thinks that from Sij to Siij is the full amount of a 
healthy period, and that the quantity cannot habitually exceed this 
without producing serious constitutional effects. Rich diet, luxurious 
living, and anything that unhealthily stimulates the body and mind, 
will have an injurious effect in increasing the flow, which is, therefore, 
less in hard-worked countrywomen than in the better classes and 
residents in towns. 

It is more abundant in warm climates, and our countrywomen in 
India habitually menstruate over-profusely, becoming less abundantly 
unwell when they return to England. The same observation has been 
made with regard to American women residing in the Gulf States, who 
improve materially by removing to the Lake States. Some Avomen 
appear to menstruate more in summer than in winter. I am acquainted 
with a lady who spends the winter in St. Petersburg, where her periods 
last eight or ten days, and the summer in England, where they never 
exceed four or five. The difference is probably due to the effect of the 
overheated rooms in which she lives in Russia. 

The daily loss is not the same during the continuance of the period. 
It generally is at first slight, and gradually increases so as to be most 
profuse on the second or third day, and as gradually diminishes. 
Toward the last days it sometimes disappears for a few hours, and 
then comes on again, and is apt to recur under any excitement or 
emotion. 



90 ORGANS CONCERNED IN PARTURITION. 

As the menstrual fluid escapes from the uterus it consists of pure 
blood, and if collected through the speculum, it coagulates. The 
ordinary menstrual fluid does not coagulate unless it is excessive in 
amount. Various explanations of this fact have been given. It was 
formerly supposed either to contain no fibrin, or an unusually small 
amount. Ketzius attributes its non-coagulation to the presence of free 
lactic and phosphoric acids. The true explanation was first given by 
Mandl, who proved that even small quantities of pus or mucus in 
blood were sufficient to keep the fibrin in solution; and mucus is 
always present to greater or less amount in the secretions of the cervix 
and vagina, which mix with the menstrual blood in its passage through 
the genital tract. If the amount of blood be excessive, however, the 
mucus present is insufficient in quantity to produce this effect, and 
coagula are then formed. 

On microscopic examination the menstrual fluid exhibits blood 
corpuscles, mucous corpuscles, and a considerable amount of epithelial 
scales, the last being the debris of the epithelium lining the uterine 
cavity. According to Virchow, the form of the epithelium often 
proves that it comes from the interior of the utricular glands. The 
color of the blood is at first dark, and as the period progresses it gen- 
erally becomes lighter in tint. In women who are in bad health it is 
often very pale. These differences doubtless depend upon the amount 
of mucus mingled with it. The menstrual blood has always a char- 
acteristic faint and heavy odor, which is analogous to that which is 
so distinct in the lower animals during the rut. Kaciborski mentions 
a lady who was so sensitive to this odor that she could always tell to 
a certainty when any woman was menstruating. It is attributed either 
to decomposing mucus mixed with the blood, which, when partially 
absorbed, may cause the peculiar odor of the breath often perceptible 
in menstruating women; or to the mixture with the fluid of the 
sebaceous secretion from the glands of the vulva. It probably gave 
rise to the old and prevalent prejudices as to the deleterious properties 
of menstrual blood, which are very widely spread. Even at the pres- 
ent day, in many farms, menstruating womeu are not allowed to make 
butter or cheese, or to prepare hams, or cook fruit or preserves. 

It is now universally admitted that the source of the menstrual 
blood is the mucous membrane lining the interior of the uterus, for 
the blood may be seen oozing through the os uteri by means of the 
speculum, and in cases of prolapsus uteri ; while in cases of inverted 
uterus it may be actually observed escaping from the exposed mucous 
membrane, and collecting in minute drops upon its surface. During 
the menstrual nisus the whole mucous lining becomes congested to 
such an extent that, in examining the bodies of women who have died 
during menstruation, it is found to be thicker, larger, and thrown into 
folds, so as to completely fill the uterine cavity. The capillary cir- 
culation at this time becomes very marked, and the mucous membrane 
assumes a deep-red hue, the network of capillaries surrounding the 
orifices of the utricular glands being especially distinct. These facts 
have an unquestionable connection with the production of the dis- 
charge, but there is much difference of opinion as to the precise mode 



OVULATION AND MENSTRUATION. 91 

in which the blood escapes from the vessels. Coste believed that the 
blood transudes through the coats of the capillaries without any 
laceration of their structure. Farre inclined to the hypothesis that the 
uterine capillaries terminate by open mouths, the escape of blood 
througn these, between the menstrual periods, being prevented by 
muscular contraction of the uterine walls. Pouchet believed that 
during each menstrual epoch the entire mucous membrane is broken 
down and cast off in the form of minute shreds, a fresh mucous mem- 
brane being developed in the interval between two periods. During 
this process the capillary network would be laid bare and ruptured, 
and the escape of blood readily accounted for. Tyler Smith, who 
adopted this theory, states that he has frequently seen the uterine 
mucous membrane, in women who have died during menstruation, in 
a state of dissolution, with the broken loops of the capillaries exposed. 
The phenomena attending the so-called membranous dysmenorrhea, 
in which the mucous membrane is thrown off in shreds, or as a cast 
of the uterine cavity — the nature of which was first pointed out by 
Simpson and Oldham — have been supposed to corroborate this theory. 
This view is, in the main, corroborated by the recent researches of 
Engelmann, 1 AVilliams, 2 and others. Williams describes the mucous 
lining of the uterus as undergoing a fatty degeneration before each 
period, which commences near the inner os, and extends over the whole 
mucous membrane, and down to the muscular wall. This seems to 
bring on a certain amount of muscular contraction, which drives the 
blood into the capillaries of the mucosa, and these, having become 
degenerated, readily rupture, and permit the escape of the blood. The 
mucous membrane now rapidly disintegrates, and is cast off in shreds 
with the menstrual discharge, in which masses of epithelial cells may 
always be detected. Engelmann, however, holds that the fatty degen- 
eration is limited to the superficial layers, and that a portion only of 
the epithelial investment is thrown off. As soon as the period is over, 
the formation of a new mucous membrane is begun, which arises either 
from proliferation of the elements of the muscular coat itself, or from 
the proliferation of the epithelial cells lining the bases of the uterine 
glands which remain imbedded in the muscular tissue after the mucous 
membrane has been thrown off, and at the end of a week the whole 
uterine cavity is lined by a thin mucous membrane. This grows until 
the advent of another period, when the same degenerative changes 
occur unless impregnation has taken place, in which case it becomes 
further developed into the decidua. Lowenthal 3 believes that the 
menstrual decidua is produced by the imbedding of an ovum in the 
lining membrane of the uterus, which, if impregnation occurs, is 
developed into the decidua of pregnancy. If conception does not 
take place, the ovum dies, and this is followed by the degeneration 
and expulsion of the menstrual decidua, accompanied by a flow of 
bloodV, which is the menstrual discharge. 

i American Journal of Obstetrics, 1875-76. vol. viii. p. 30. 

2 "On the Structure of the Mucous Membrane of the Uterus," Obstet. Journ., 1875-76, vol. iii. 
p. 496. 

3 Arch. f. Gyn., Bd. xxiv., Heft 2, S. 169: "Eine neue Deutung des Menstruations-Prozess." 



92 ORGANS CONCERNED IN PARTURITION. 

Theory of Menstruation. — That there is an intimate connection 
between ovulation and menstruation is admitted by most physiologists, 
and it is held by many that the determining cause of the discharge is 
the periodic maturation of the Graafian follicles. There is abundant 
evidence of this connection, for we know that when, at the change of 
life, the Graafian follicles cease to develop, menstruation is arrested ; 
and when the ovaries are removed by operation, of which there are now 
numerous cases on record, or when they are congenitally absent, men- 
struation does not generally take place. A few cases, however, have 
been observed in which menstruation continued after double ovari- 
otomy, or the removal of the ovaries by Battey's operation, and these 
have been used as an argument by those physiologists who doubt the 
ovular theory of menstruation. Slavyansky has particularly insisted 
on such cases, which, however, are probably susceptible of explanation. 
It may be that the habit of menstruation may continue for a time even 
after the removal of the ovaries ; and it has not been shown that men- 
struation has continued permanently after double ovariotomy, although 
it certainly has occasionally, although quite exceptionally, done so for 
a time. It is possible, also, that in such cases a small portion of ovarian 
tissue may have been left unremoved, sufficient to carry on ovulation. 
Roberts, a traveller quoted by Depaul and Gueniot in their article on 
Menstruation in the Dictionnaire des Sciences Medicates, relates that in 
certain parts of Central Asia it is the custom to remove both ovaries in 
young girls who act as guards to the harems. These women, known 
as "hedjeras," subsequently assume much of the virile type, and never 
menstruate. The same close connection between ovulation and the rut 
of animals is observed, and supports the conclusion that the rut and 
menstruation are analogous. The chief difference between ovulation 
in man and the lower animals is that in the latter the process is not 
generally accompanied by a sanguineous flow. To this there are excep- 
tions, for in monkeys there is certainly a discharge analogous to men- 
struation occurring at intervals. Bland Sutton 1 and Heape have made 
careful studies of menstruation in monkeys and baboons. The former 
states that in these animals there is no shedding of the mucous mem- 
brane of the uterus, or of the utricular glands, while Heape, 2 whose 
investigations were carried out in India, finds the process similar to 
that in the human race, although more irregular. 

Another point of distinction is that in animals connection never 
takes place except during the rut, and that it is then only that the 
female is capable of conception ; while in the human race conception 
only occurs in the interval between the periods. This is another argu- 
ment brought against the ovular theory, because, it is said, if menstrua- 
tion depend on the rupture of a Graafian follicle and the emission of 
an ovule, then impregnation should only take place during or imme- 
diately after menstruation. Coste explains this by supposing that it is 
the maturation and not the rupture of the follicle which determines the 
occurrence of menstruation ; and that the follicle may remain unrup- 
tured for a considerable time after it is mature, the escape of the ovule 

i Brit. Gyn. Journ., vol ii. 2 philos. Trans.. 1894. 



OVULATION AND MENSTRUATION. 93 

being subsequently determined by some accidental cause such as sexual 
excitement. However this may be, there is good reason to believe that 
the susceptibility to conception is greater during the menstrual epochs. 
Eaciborski believes that in the large proportion of cases impregnation 
occurs in the first half of the menstrual interval, or in the few davs 
immediately preceding the appearance of the discharge. There are, 
however, very numerous exceptions, for in Jewesses, who almost inva- 
riably live apart from their husbands for eight days after the cessation 
of menstruation, impregnation must constantly occur at some other 
period of the interval, and it is certain that they are not less prolific 
than other people. This rule with them is very strictly adhered to, as 
will be seen by the accompanying interesting letter from a medical 
friend who is a well-known member of that community, and which I 
have permission to publish. 1 This fact is of itself sufficient to disprove 
the theory advanced by Dr. Avrard, 2 that impregnation is impossible 
in the latter half of the menstrual interval. This, and the other reasons 
referred to, undoubtedly throw some doubt on the ovular theory, but 
they do not seem to be sufficient to justify the conclusion that men- 
struation is a physiological process altogether independent of the 
development and maturation of the Graafian follicles. All that they 
can be fairly held to prove is that the escape of the ovules may occur 
independently of menstruation. 

It should be stated that several recent writers, Lawson Tait amongst 
the number, attribute considerable influence in menstruation to the 
Fallopian tubes. Robinson, of Chicago, in an interesting paper, 3 con- 
tends that menstruation is governed by nervous ganglia situated in the 
walls of the Fallopian tubes and uterus, which he calls "automatic 
menstrual ganglia." These he considers to be analogous to the nerve 
ganglia found in the heart, intestines, and other hollow viscera, and to 
have the function of producing rhythmical peristalsis in the tubes, 
which favors the passage of the ovum along their canal. He believes 
that ovulation is entirely unconnected with menstruation, and goes on 

1 10 Bernard Street, Russell Square, July 21, 1873. 
My dear Sir: 1. To the best of my knowledge and belief, the law which prohibits sexual 
intercourse among Jews for seven clear days after the cessation of menstruation, is almost 
universally observed, the exceptions not being sufficient to vitiate statistics. The law has perhaps 
fewer exceptions on the Continent — especially Russia and Poland, where the Jewish population is 
very great — than in England. Even here, however, women who observe no other ceremonial law 
observe this, and cling to it after everything else is thrown overboard. There are doubtless many 
exceptions, especially among the better classes in England, who keep only three days after the 
cessation of the menses. 

2. The law is— as you state— that should the discharge last only an hour or so. or should there be 
only one gush or one spot on the linen, the five days during which the period might continue are 
observed ; to which must be superadded the seven clear days — twelve days per mensem in which 
connection is disallowed. Should any discharge be seen in the inter- menstrual period, seven days 
would have to be kept, but not the five, for such irregular discharge. 

3. The "bath of purification," which must contain at least eighty gallons, is used on the last 
night of the seven clear days. It is not used till after a bath for cleansing purposes ; and, from 
the night when such " purifying " bath is used, Jewish women are accustomed to calculate the 
commencement of pregnancy. That you should not have heard it is not strange ; its mention 
would be considered highly indelicate. 

4. Jewish women reckon their pregnancy to last nine calendar or ten lunar months— 270 to 280 
days. There are no special data "on which to reckon an average, nor do I know of any books on 
the subject, except some Talmu lie authorities, which I will look up for you if you desire it. Pray 
make no apologies for writing to me : any information I possess i« at your service. 

I am, dear Sir, yours very truly, 
Dr. Playfair. A. Asher. 

P. S.— The Biblical foundation for the law of the seven clear days is Leviticus xv., verse 19 till 
the end of the chapter— especially verse 28. 

2 Rev. de Therap. Med.-Chir., 1867. 

3 American Journal of Obstetrics, Sept. 1891. 



94 ORGANS CONCERNED IN PARTURITION. 

independently of it, the greater part of the ovules being lost in the 
peritoneal cavity; and that it is only when the periodic and rhythmical 
action of the tubes begins that menstruation is established. These 
views caunot be taken as proved, but they certainly suggest an explana- 
tion of some of the phenomena of menstruation otherwise difficult to 
understand, such as its occasional continuance after the removal of the 
ovaries, and are well worthy of further investigation. Leith Napier 1 
also refers menstruation to nerve action. He holds that the growth 
of the utricular glands preceding the discharge produces peripheral 
nerve irritation, which is conveyed to centres in the cord and cerebel- 
lum, and subsequently efferent nervous impulses result in the growth 
of uterine stroma and vessels, the menstrual flow itself being produced 
by the breaking down of the congested uterine capillaries, and the 
probable shedding of the superficial epithelium. 

The cause of the monthly periodicity is quite unknown, and will 
probably always remain so. Goodman has suggested what he calls the 
" cyclical theory of menstruation," which refers the phenomena to a 
general condition of the vascular system, specially localizing itself in 
the generative organs, and connected with rhythmical changes in their 
nerve-centres. It does not seem to me, however, that he has satis- 
factorily proved the recurrence of the conditions which his ingenious 
theory assumes. The purpose of the loss of so much blood is also 
semewhat obscure. To a certain extent it must be considered an acci- 
dent or complication of ovulation, produced by the vascular turgescence. 
Nor is it essential to fecundation, because women often conceive during 
lactation, Avhen menstruation is suspended ; or before the function has 
become established. It may, however, serve the negative purpose of 
relieving the congested uterine capillaries which are periodically filled 
with a supply of blood for the great growth which takes place when 
conception has occurred. Thus, immediately before each period the 
uterus may be considered to be placed by the afflux of blood in a state 
of preparation for the function it may suddenly be called upon to per- 
form. That the discharge relieves a state of vascular tension which 
accompanies ovulation is proved by the singular phenomenon of 
vicarious menstruation which is 'occasionally, though rarely, met with. 
It occurs in cases in which, from some unexplained cause, the discharge 
does not escape from the uterine mucous membrane. Under such cir- 
cumstances a more or less regular escape of blood may take place from 
other sites. The most common situations are the mucous membranes 
of the stomach, of the nasal cavities, or of the lungs ; the skin, not 
uncommonly that of the mammae, probably on account of their intimate 
sympathetic relation with the uterine organs ; from the surface of an 
ulcer ; or from hemorrhoids. It is a noteworthy fact that in all these 
cases the discharge occurs in situations where its external escape can 
readily take place. This strange deviation of the menstrual discharge 
may be taken as a sign of general ill-health, and it is usually met with 
in delicate young women of highly mobile nervous constitution. It 
may, however, begin at puberty, and it has even been observed during 

i The Menopause and its Disorders, 1897, pp. 45, 46. 



OVULATION AND MENSTRUATION. 95 

the whole sexual life. The recurrence is regular, and always in con- 
nection with the menstrual nisus, although the amount of blood lost is 
generally much less than in ordinary menstruation. 

Cessation of Menstruation. — After a certain time changes occur, 
showing that the woman is no longer fitted for reproduction ; men- 
struation ceases, Graafian follicles are no longer matured, and the ovary 
becomes shrivelled and wrinkled on its surface. Analogous alterations 
take place in the uterus and its appendages. The Fallopian tubes 
atrophy, and are not unfrequently obliterated. The uterus decreases 
in size. The cervix undergoes a remarkable change, which is readily 
detected on vaginal examination ; the projection of the cervix into the 
vaginal canal disappears, and the orifice of the os uteri in oil women 
is found to be flush with the roof of the vagina. In a large number 
of cases there is, after the cessation of menstruation, an occlusion both 
of the external and internal os ; the canal of the cervix between them, 
however, remains patulous, and is not unfrequently distended with a 
mucous secretion. 

Period of Cessation. — The age at which menstruation ceases varies 
much in different women. In certain cases it may cease at an unusually 
early age, as between thirty and forty years, or it may continue far 
beyond the average time, even up to sixty years; and exceptional, 
though perhaps hardly reliable, instances are recorded, in which it has 
continued even to eighty or ninety years. These are, however, strange 
anomalies, which, like cases of unusually precocious menstruation, 
cannot be considered as having any bearing on the general rule. Most 
cases of so-called protracted menstruation will be found to be really 
morbid losses of blood depending on malignant or other forms of 
organic disease, the existence of which, under such circumstances, 
should always be suspected. 

In England menstruation usually ceases between forty and fifty 
years of age. Kaciborski says that the largest number of cases of 
cessation are met with in the forty-sixth year. It is generally said 
that women who commence to menstruate when very young cease to 
do so at a comparatively early age, so that the average duration of the 
function is about the same in all women. Cazeaux and Kaciborski, 
whose opinion is strengthened by the observations of Guy in 1500 
cases, 1 think, on the contrary, that the earlier menstruation commences 
the longer it lasts, early menstruation indicating an excess of vital 
energy which continues during the whole childbearing life. Climate 
and other accidental causes do not seem to have as much effect on the 
cessation as on the establishment of the function. It does not appear 
to cease earlier in warm than in temperate climates. The change of 
life, or menopause, as the time of cessation is frequently called, is gen- 
erally indicated by irregularities in the recurrence of the discharge. 
It seldom ceases suddenly, but it may be absent for one or more 
periods, and then occur irregularly ; or it may become profuse or scanty, 
until eventually it entirely stops. The popular notions as to the 
extreme danger of the menopause are probably much exaggerated ; 

i Med. Times and Gaz., 1845. 



96 ORGANS CONCERNED IN PARTURITION. 

although it is certain that at that time various nervous phenomena 
are apt to be developed. So far from having a prejudicial effect on 
the health, however, it is not an uncommon observation to see an 
hysterical womau, who has been for years a martyr to uterine and 
other complaints, apparently take a new lease of life when her uterine 
functions have ceased to be in active operation ; and statistical tables 
abundantly prove that the general mortality of the sex is not greater 
at this than at any other time. 



PART II. 

PREGNANCY. 



CHAPTER I. 

CONCEPTION AND GENERATION. 



Reproduction in the human female, as in all mammalian animals, 
requires the congress of the sexes, in order that the spermatozoon, the 
male element of generation, may be brought into contact with the ovum, 
the female element of generation. The introduction of the male ele- 
ment to the genital passages of the female is termed impregnation ; the 
union of the male and female elements is termed .fertilization. The 
fertilization of the ovum is the initial stage of the process of develop- 
ment. 

The medium through which the spermatozoa gain access to the 
genital passages of the female is the semen, which is deposited in the 
vagina at the completion of the sexual orgasm. The semen is a viscid, 
opalescent fluid, consisting of the mixed secretions of the testes, the 
prostate, and Cowper's glands. It consists chemically of a solution 
of an albuminous substance called spermatin, and various inorganic 
salts, chiefly chlorides and phosphates. Examined under the micro- 
scope it is seen to contain floating particles consisting of squamous and 
columnar epithelial cells, certain highly refracting globules (seminal 
globules), and spermatozoa. The seminal granules are minute color- 
less particles, probably derived from the nuclei of disintegrated cells 
of the seminiferous tubules. The spermatozoa are derived from the 
intermediate or proliferating layer of cells of the same tubules (Fig. 
45). Each consists of a flattened oval head, a slender filiform tail, and 
an intermediate portion, or middle-piece, connecting the two. The 
head is -g^oo °f aQ ^ ncu l° n & an( ^ ToTTolT Dr °ad ; the tail is from -^-^ 
to 5^-g- of an inch long. A delicate undulating membrane is attached 
to the tail of the spermatozoon in many animals, the unattached border 
of which is bounded by a long, fine filament, and, being much longer 
than the tail itself, this border is thrown into many waving folds. 
The presence of this membrane has not been demonstrated in man. 
For many hours after their removal or discharge from the body the 
spermatozoa exhibit active lashing movements of the tail, which propel 
them in a spiral course through the fluid in which they float, and, when 

7 (97) 



98 



PREGNANCY, 



kept at the body-temperature, they retain their motility for many 
hours. It is by this means that they make their way through the 
female genital passages to meet the ovum. Many other forces have 
been suggested by different writers as contributing to their progress, 
e.g., peristaltic contractions of the uterus and Fallopian tubes, capillary 
attraction, suction on the part of the uterus acting during the sexual 
orgasm, etc.; but there can be no doubt that the spermatozoa are able, 
by their own mobility, to make their way upward through the uterus. 

Fig. 45. 




Section of parts of three seminiferous tubules of the rat. a. With the spermatozoa least advanced 
in development, b. More advanced, c. Containing fully-developed spermatozoa. Between the 
tubules are seen strands of interstitial cells and lymph spaces. (From a preparation by Mr. A. 
Frazeb.) 

The transit of the spermatozoa from the vagina through the 
uterus to the Fallopian tubes occurs in a few hours in animals ; it is 
therefore probable that in the human female also the process is a 
rapid one, although there are no direct observations available upon 
the point. The resting-place of the spermatozoa appears to be not the 
uterus, but the outer part, or infundibulum, of the tube, where they 
lie among the folds of the arborescent tubal mucosa. In this position 
they may retain their vitality for a remarkably long period. Thus 
Duhrssen 1 reports a case in which he removed the appendages from a 
woman who had been nine days under observation in hospital, and 
found a number of active spermatozoa in one of the tubes ; she stated 
that the last coitus occurred three and a half weeks before the opera- 
tion. Those which remain in the vagina perish within twelve hours, 
and free leucorrhoeal discharges destroy them much more rapidly, and 
may thus lead to sterility in the female. In animals killed soon after 
impregnation, spermatozoa may often be found in active motion upon 
the surface of the ovary, and wandering freely in the peritoneal cavity. 
There is reason to believe, however, that the usual meeting-place of 



1 Ceutralblatt fQr Gyniikologie, 1893, p. 593. 



CONCEPTION AND GENERATION. 99 

the ovum and the spermatozoon is the outer part of the tube, the ovum 
being conveyed thither along the fimbriae by the action of the ciliated 
epithelium. When it leaves the ruptured Graafian follicle the ripe 
ovum consists of the following parts : (1) A.n irregular covering of 
rounded cells, the zona granulosa or discus proligerus; (2) a double 
row of columnar cells, the corona; (3) the envelope proper of the 
ovum, the vitelline membrane or 2071a radiata ; (4) the vitellus or 
yelk ; (5) its nucleus, the germinal vesicle (Fig. 46). Before it reaches 
the resting-place of the spermatozoa the two outer cellular coats are 
lost, and an albuminous covering, derived from the tubal epithelium, 
replaces them ; in birds this albuminous coat is enormously developed, 
forming the familiar " white" of the egg. In this manner ovum and 
spermatozoon are brought together, and fertilization becomes possible. 
Only one spermatozoon is required for the fertilization of a single 
ovum ; the enormous numbers introduced at each coitus perish without 
achieving their physiological destiny. 



Fig. 46. 









im% 



Human ovum from a small Graafian follicle. K. Germinal vesicle with two nucleoli. D. Vitellus 
or yelk. Zp. Zona, radiata. C. Corona. Zg. Zoua granulosa or discus proligerus. tAfter Nagel.) 

The details of the process of fertilization in the human species are, 
of course, unknown. They have been worked out with precision, 
however, in the case of many invertebrates, and especially in certain 
echinoderms and ascarides, which possess transparent ova, and are 
therefore peculiarly favorable for such observations. Van Beneden 
has also succeeded in tracing certain stages of the process in the rabbit. 
But the beginnings of development have not yet been made out with 
precision in any of the mammalia, and it must be understood that the 
account of the process which follows is assumed by analogy to occur 
in the human ovum, but has not been actually observed by anyone. 

Before the ovum and spermatozoon meet, certain preparatory changes 
occur in the former which are admitted to be of great importance 



100 PREGNANCY. 

although their significance is not understood. The germinal vesicle, 
or nucleus, first approaches the periphery, becomes indistinct in out- 
line, and undergoes changes typical of a nucleus about to segment 
(karyokinetic changes) ; a small portion of its substance, surrounded 
by a ring of protoplasm, is then separated and extruded between the 
zone radiata and the yelk. The germinal vesicle then recedes toward 
the centre of the ovum, and again approaching a different spot of the 
periphery, extrudes a second portion of its substance in like manner. 
These extruded portions of the germinal vesicle are called the polar 
globules. The remainder of the vesicle, which is now called the female 
pro-nucleus, recedes once more from the periphery, and awaits the 
coming of the spermatozoon. The polar globules themselves soon 
disappear. These preparatory changes occur in all ripened ova, 
whether they become fertilized or not. 

The ovum thus prepared is penetrated by a spermatozoon, which 
probably directly pierces the zone radiata, as there is no micropyle in 
the human ovum. On entering the vitellus the tail disappears, the 
head alone remaining ; this is now called the male pro-nucleus. Around 
it radial lines appear in the vitellus, forming a stellate arrangement. 
The male and female pro-nuclei now approach one another and fuse, 
forming a single nucleus, called the segmentation nucleus, and com- 
pleting the act of fertilization. Observers are at variance as to what 
occurs if an ovum is penetrated by more than one spermatozoon ; prob- 
ably all perish except the one which actually fuses with the female 
pro-nucleus. The ovum has now acquired the power of forming new 
cells by division, and all the tissues of the body are developed from it 
by cell multiplication and differentiation. 

After the fusion of the male and female pro-nuclei a pause has been 
observed to occur in several invertebrates, lasting from half to three- 
quarters of an hour (Minot) j 1 the process of segmentation of the ovum 

1 Fig. 47. 2 




Segmentation of the ovum. 1. Division of the segmentation nucleus. 2. Formation of equatorial 
fissure and further division of nuclei. (After Ahlfeld.) 

then commences. The segmentation nucleus first undergoes karyokinetic 
changes, and then divides into two halves, which retreat toward op- 
posite poles of the ovum, while radial lines appear around them in the 

• ' Segmentation of the Ovum," American Naturalist, June, 1889, p. 464. 



CONCEPTION AND GENERATION. 



101 



protoplasm. An equatorial line of division is then formed between 
them, which divides the whole ovum into two cells (Fig. 47). The 
same changes now occur in each of the new cells, and thus, by a pro- 
cess of biniary division, the ovum multiplies into 2, 4, 8, 16, 32, etc., 
cells. In the mammalia the w T hole ovum segments, and is therefore 
called holoblastic, in contradistinction to that of fishes, reptiles, birds, 
etc., in which a part only of the protoplasm participates, the ovum 
being called mesoblastic. In this manner the mammalian ovum is 



Fig. 48. 










Sections of the ovum of the rabbit during the later stages of segmentation, showing the forma- 
tion of the blastodermic vesicle, a. Section showing the enclosure of entomeres, ent., by ecto- 
meres, ect., except at one spot— the blastopore, b. More advanced stage, in which fluid is begin- 
ning to accumulate between the entomeres and ectomeres, the former completely enclosed, c. The 
fluid has much increased, so that a large space separates entomeres from ectomeres, except at one 
part. d. Blastodermic vesicle, its wall formed of a layer of ectodermic cells, with a patch of ento- 
meres adhering to it at one part, z.p., ect., ent. As before. (After E. v. Beneden.) 

converted into a solid cluster or globe of cells, often called the muri- 
form body. In the rabbit, according to Van Beneden, 1 the cells of the 
muriform body are of two kinds, clear cells placed peripherally, and 
granular cells occupying the centre (Fig. 48). The mass next increases 
rapidly in size by the formation of fluid within it, which accumulates 
between the clear cells and the granular cells, separating them from 
one another at all but one part of the sphere. The superficial (clear) 



1 " Recherches sur l'Embryologie des Mammiferes," Archiv. de Biologie, 1880. 



102 PREGNANCY. 

cells now multiply rapidly, and, becoming flattened out by excentric 
pressure, and applied to the zona radiata, they form a complete wall of 
cells within that membrane. The deep (granular) cells have not mul- 
tiplied to the same extent, and appear as a little mass, attached at one 
spot to the deep surface of the superficial layer. At this stage the 
ovum is called the blastodermic vesicle ; it consists of (1) the zona 
radiata, (2) an outer complete wall of clear cells, (3) a deep, incomplete 
wall of granular cells, (4) a quantity of fluid. 

The next stage is the formation of the blastoderm. The deep gran- 
ular cells proliferate more rapidly, and spread out within the outer 
layer, at first in the form of a lenticular patch, but gradually extending 
until a complete layer is formed. Over a small area, these two layers 
now become slightly separated from one another, forming together the 
bi-laminar blastoderm. An oval area of thickening, formed by pro- 
liferation of the cells of both layers, now appears upon the surface of 
the ovum, and is known as the embryonic area. Soon a delicate longi- 
tudinal ridge, formed by proliferation of the cells of the outer layer 
(now often called the primitive ectoderm), may be traced along the em- 
bryonic area; this is called the primitive streak, and upon the ridge 
appears a shallow longitudinal groove, the primitive groove. Along 
the line of the primitive streak the cells of the inner layer (now often 
called the primitive entoderm) also proliferate, and come into contact 
once more with those of the outer layer (Fig. 49). From this line of 
contact is developed a third layer of cells, which spreads in the interval 



Fig 




The tri-laminar blastoderm, p.sk. Primitive streak, p.gr. Primitive groove, ep. Epiblast. hy. 
Hypoblast, m. Mesoblast. (After Quain.) 

between the outer and inner layers ; it is derived mainly from the 
primitive ectoderm, but also, in part, from the primitive entoderm. 
The blastoderm now consists of three layers (tri-laminar blastoderm), 
which are called ectoderm, mesoderm, and entoderm, or epiblast, meso- 
blast, and hypoblast, respectively. From these three layers all the 
tissues of the body are developed, but a text-book of embryology 
should be consulted for an account of the parts formed from each. 

Soon after the appearance of the mesoblast a shallow longitudinal 
groove, the medullary groove, is formed upon the embryonic area, in 
front of the primitive streak. It is produced by the formation of two 
parallel folds of epiblast, called the medullary folds. These grow 
over to meet one another, and coalesce in the middle line, forming an 
included canal with an epiblast lining (the neural canal), from which 
the whole central nervous system is developed. Daring these changes 
the primitive streak disappears. While the neural canal is develop- 



CONCEPTION AND GENERATION, 



103 






ing there is formed beneath it a solid roll of proliferating hypoblast 
cells, called the notochor*d. At the sides of the neural canal a great 
development of mesoblast cells takes place, forming large lateral 
masses, which become marked out by trausverse grooves into a row 
of solid blocks called the mesoblastic somites. From these cell-masses 
most of the skeletal and muscular tissues of the body are developed. 
At the same time that the mesoblastic somites are formed the more 
outlying parts of the mesoblast split into two layers ; the outer becomes 
applied to the epiblast ; and the two together form the somoto-pleure ; 
the inner becomes similarly applied to the hypoblast, the two together 
forming the splanchno-pleure. The space between the somato-pleure 
aud the splanchno-pleure is the cadom, or primitive body-cavity 
(Fig. 50). 

Fig. 50. 




Stages in the conversion of the medullary groove into the neural canal. From the tail end of 
an embryo of the cat. m.g. Medullary groove, n.c. Neural canal, eh. Notochord. ep. Epiblast. 
hy. Hypoblast, me. Mesoblast. ex. Ccelum. am. Amnion. (After Quain). 



It will be understood that the above-mentioned changes have taken 
place upon a certain small area (embryonic area) of the surface of the 



104: PREGNANCY. 

blastodermic vesicle, and, of course, within the zona radiata. The 
next step is the delimitation of the outlines of the embryo by the for- 
mation of the anterior, posterior, and two lateral limiting sulci. At 
the same time, the embryonic area begins to recede toward the centre 
of the blastodermic vesicle — sinking, that is, into its anterior, and 
leaving a space between it and the enclosing zona radiata. The fur- 
ther steps in the development of the body of the embryo cannot be 
entered upon in this work. But a period has now been reached when 
certain structures designed to provide for the protection and nutrition 
of the embryo make their appearance. They are called the foetal en- 
velopes or membranes, and consist of the amnion and the chorion. The 
function of the amnion is protective only ; the chorion serves to bring 
the body of the embryo into vital organic union with the maternal 
structures. With the development of these membranes we are now 
mainly concerned. 

Although differing widely in their functions, and in the form which 
they ultimately assume, these two membranes have precisely the same 
source and mode of origin. They are formed from folds of the somato- 
pleure, which grow up from the head and tail ends and lateral boun- 
daries of the embryo, and pass over its dorsal surface in the space be- 
tween it and the zona radiata. Gradually these folds coalesce, forming 
a closed hood, which consists of two distinct layers ; each layer is com- 
posed of epiblast and mesoblast, and the mesoblastic surfaces being 
apposed, the epiblast of the inner layer is directed inward, and that of 
the outer layer outward (Fig. 51). The two layers soon become sepa- 
rated by the formation of fluid between them. The outer becomes 
closely applied to the zona radiata, and, growing rapidly, soon forms 
a complete investment of the ovum, with the exception of the part at 
which the umbilical cord is afterward developed. It is known as the 
false amnion, or chorion, and will in future be referred to as the chorion. 
The inner layer covers the dorsal surface of the embryo, being sepa- 
rated from it by a quantity of fluid ; it is known as the true amnion, 
or simply as the amnion, and the fluid it contains is the liquor amnii. 
It is obvious that since both layers of the amnion are formed from an 
outward folding of the somato-pleure, the space between them is at this 
stage in direct communication with the ccelom — i. e., the interval be- 
tween the somato-pleure and the splanchno-pleure. As these changes 
proceed the embryo sinks further into the interior of the blastodermic 
vesicle, thus giving room for the formation of the membranes. 

The body-folds (somato-pleure and splanchno-pleure) now grow over 
toward the ventral surface, thus pinching the embryo off from the 
remainder of the blastodermic vesicle. The effect of this change is to 
carry the line of origin of the amniotic folds, at first dorsal in position, 
further and further over to the ventral surface of the embryo ; and as 
the ccelom becomes shut off by union of the body-folds, the amnion 
comes to be continuous with the body of the embryo at one point 
only, which is the last to close — viz., the umbilicus. This relation 
obtains throughout the remainder of intra-uterine life. 

The effect of the development of the amnion and chorion, it will be 
seen, is to isolate the embryo in the interior of the blastodermic vesicle. 



CONCEPTION AND GENERATION 
Fig. 51. 



105 




^V^ 



2T!> 



Five diagrammatic figures illustrating the formation of the foetal membranes of a mammal. In 
1, 2, 3, 4 the embryo is represented in longitudinal section. 1. Ovum with zona pellucida, blasto- 
dermic vesicle, and embryonic area. 2. Ovum with commencing formation of umbilical vesicle 
and amnion. 3. Ovum with amnion about to cease, and commencing allantois. 4. Ovum with 
villous sub-zonal membrane, larger allantois, and mouth and anus. 5. Ovum in which the meso- 
biast of the allantois has extended round the inner surface of the sub-zonal membrane and 
united with it to form the chorion. The cavity of the allantois is aborted. This figure is a dia- 
gram of an early human ovum. d. zona radiata ; d' and sz. processes of zona ; sk. sub-zonal mem- 
brane, outer fold of amnion, false amnion ; ch. chorion ; ch.z. chorionic villi , am. amnion ; ks. 
head fold of amnion ; ss. tail fold of amnion ; a. epiblast of embryo ; a', epiblast of non-embry- 
onic part of the blastodermic vesicle ; m. embryonic mesoblast ; m'. non-embryonic mesoblast; 
dj. area vasculosa ; st. sinus terminalis ; dd. embryonic hypoblast ; i. non-embryonic hypoblast; 
kh. cavity of blastodermic vesicle, the greater part of which becomes the cavity of umbilical vesi- 
cle ds; dg. stalk of umbilical vesicle; al. allantois • e. embryo; r. space between chorion and 
amnion containing albuminous fluid ; vl. ventral body wall ; hh. pericardial cavity. (After 
Kolliker). 

Direct communication with the wall of the vesicle is, however, main- 
tained by the development of the umbilical cord, a structure closely 
related in its origin to the allantois. This structure is an outgrowth 



106 PREGNANCY. 

from the hind end of the primitive alimentary canal, lined by hypo- 
blast cells, and receiving an investment of mesoblast cells in its out- 
growth. There has been great conflict of opinion upon the relation of 
the allantois to the development of the umbilical cord. According to 
the old view, when the embryo recedes toward the centre of the blasto- 
dermic vesicle, and during the formation of the amniotic folds, the 
allantois grows out to the wall of the vesicle in the interval between 
the chorion and amnion, where its mesoblast elements join those of the 
former. Along the bridge of tissue thus formed, vessels developed 
from the terminal bifurcation of the aorta (allantoics or umbilical 
vessels) pass to the chorion and vascularize it. His 1 has pointed out 
that there are important objections to this view, notably the fact that 
vessels have been found reaching the chorion by a mesoblastic stalk at 
a period when the allantois has only just appeared as a diminutive out- 
growth from the gut. He believes that when the embryo sinks into 
the blastodermic vesicle it is not entirely separated from the wall, but 
remains in contact with it through a bridge of mesoblastic tissue which 
is continuous with the ventral aspect of its tail end. This bridge he 
terms the ventral stalk. Along it the umbilical vessels pass to the 
chorion, and the allantois also grows outward in contact with it, but 
never actually reaches the chorion. According to this view the um- 
bilical cord is developed from the ventral stalk, the umbilical vessels 
which pass through it, and the allantois. Only the distal portion of 
the latter is concerned with the cord, its proximal part forming por- 
tions of the urinary and generative systems. As the tail end of the 
embryo develops, the relative position of the ventral stalk becomes 
changed, so that its point of origin is situated ultimately about the 
centre of the body (umbilicus). 

We have now reached a stage at which the embryo lies entirely 
within its bag of membranes, and connected with the outer one by a 
bridge or stalk containing vessels — the umbilical cord. The wall of 
the ovum consists of (1) the zona radiata ; (2) the chorion ; (3) the meso- 
blast tissue and vessels which reach it from the ventral stalk. The 
zona radiata soon disappears, leaving the epiblast layer of the chorion 
as the outermost part of the wall of the ovum — the part, therefore, 
which must come in contact with the maternal tissues. Soon after its 
formation the chorion develops large numbers of little tufts or processes 
growing outward, called villi. They are at first composed of epiblast 
only, later the mesoblast grows into them, and then they become vas- 
cularized by twigs from the umbilical arteries, which now traverse the 
whole extent of the chorion. At first they do not cover the entire 
superfices of the ovum, the last part to develop villi being the free 
(unattached) pole. At this stage we are able to leave analogy for 
direct observation; there is good evidence to show that the human 
ovum attains this degree of development at the end of the first week, 
and the succeeding steps to be described have been most made out in 
the human ovum itself. 

Before proceeding further, however, we must consider the attach- 

i Anatomie menschlicher Embryonen, 1880, parti. 



CONCEPTION AND GENERATION. 107 

rnents of the ovum to the maternal structures. Here also we do not 
need the help of analogy, for the relation of the foetal and maternal 
structures at the end of the first week have been accurately described 
by Leopold. 1 

As we have seen, it is probable that fertilization usually occurs 
in the Fallopian tube, and the fertilized ovum is then carried on to the 
uterus by the action of the ciliated epithelium. The time taken by the 
ovum in its transit, and the consequent period at which it reaches the 
uterus, are unknown. We know, however, that by the end of the 
first week certain well-marked changes have occurred in the endome- 
trium, and that the ovum is in intimate relation with it. 

The time-honored view that the endometrium is in some way pre- 
pared by the process of menstruation for the reception of a fertilized 
ovum has much to be said in its favor ; but that such preparation is 
not essential is proved by the well-known fact that pregnancy not in- 
frequently occurs quite independently of it. We may therefore say 
that a fertilized ovum may be successfully implanted upon either a 
quiescent endometrium or on an endometrium altered by recent men- 
struation. The structure of the endometrium in the quiescent stage 
has been described in a previous chapter, but the changes which accom- 
pany mensturation must be briefly alluded to here. 

From observations upon the human uterus itself (Minot 2 and others) 
we know that the earliest changes in menstruation are hyperemia and 
swelling of the mucous membrane, associated with hyperplasia of its 
connective-tissue elements. The glands become dilated and contorted, 
and their epithelium proliferates ; the connective-tissue elements mul- 
tiply, and, according to some, a marked infiltration with leucocytes 
occurs. No trace is, however, found of the large decidual cells so well 
known in connection with pregnancy. Hemorrhages occur in the 
superficial layers, but whether from actual rupture of vessels is not 
made out ; it is, however, certain that no considerable vessels rupture. 
In consequence of these hemorrhages the superficial layers are broken 
up and cast off along with the covering epithelium, and become mixed 
with the blood oozing from the denuded surfaces to form the menstrual 
discharge. If a fertilized ovum does not arrive, the stage of activity 
subsides and the damage done is soon repaired, the epithelial layer being 
regenerated from glandular remains. "Under the stimulus of the pres- 
ence of a fertilized ovum, however, the membrane enters upon a new 
career, and becomes the decidua of pregnancy. The changes thus 
resulting have been termed by Clarence Webster 3 the " genetic reaction." 
They occur not only at the site of implantation of the ovum, but much 
more widely ; thus, in uterine pregnancy the whole endometrium of 
the body of the uterus shows decidual changes, and sometimes scattered 
areas of the tubal mucosa also ; and in tubal pregnancy the uterus 
develops a decidua differing but slightly from that of uterine preg- 
nancy. The cervical mucosa, on the other hand, never shows the 
genetic reaction. We are only concerned here with the changes in the 

I Uterus una* Kind, 1897. 

a u Uterus and Embryo," The Journal of Morphology, 1889. 

3 Ectopic Pregnancy, 1895, p. 11. 



108 



PREGNANCY 



endometrium in uterine pregnancy — i, e., when a fertilized ovum be- 
comes implanted upon it. 

The Decid.ua. — It is usual to distinguish three divisions of the 
decidua : the decidua serotina is the portion which corresponds to the 
site of attachment of the ovum and partakes in the formation of the 
placenta ; the decidua reflexa is the portion which, at a very early 
period, grows over the ovum so as to enclose it ; the decidua vera is 
the remaining portion, covering the greater part of the uterine surface, 
which has no direct relation to the ovum at all. All parts of the de- 
cidua are essentially alike in structure as well as in origin. 

The decidua reaches its full development in the first month ; it then 
differs from the endometrium in the following points (Eden 1 ) : — 1. 
The connective-tissue corpuscles become converted into large cells of 
epithelioid type, furnished with one or two large nuclei, and having a 
large amount of perinuclear protoplasm. These are the " decidual 
cells," but it must be remembered that they are merely large connec- 
tive-tissue corpuscles, differing in no respect from similar cells found 
in other parts of the body (Fig. 52). 2. The glands undergo remark- 

FlG. 52. 




Section of the decidua at the sixth week. D.C. Decidual celis, B.C. Clusters of small round 
cells. Cap. Dilated capillaries. Hxm. Interstitial hemorrhage. Gld. Glandular channel. Art. 
Arteries. (After Eden). 

able proliferation, with dilatation of their lumen ; these changes are most 
marked in the deeper portions of the membrane. 3. In consequence 
of these glandular changes the decidua becomes roughly divided into 



Journal of Pathology, January, 1896, p. 450. 



CONCEPTION AND GENERATION. 



109 



two layers, a superficial compact, and a deep ampullary layer, the am- 
pullae being the dilated glandular channels. 4. The vascularity of the 
membrane is very greatly increased, and numerous small interstitial 
hemorrhages are produced. 

The decidua vera does not advance beyond this stage ; in the later 
months of gestation it almost disappears by atrophy. The decidua 
reflexa is mainly an outgrowth from the compact layer, and its gland- 
ular elements are therefore not so abundant as those of other parts of 
the decidua. Its main function is protective ; it serves to support the 
rapidly growing ovum and bind it to the uterine wall while the 
placental attachments are being developed, and many of the early 
chorionic villi are directly imbedded in it (Figs. 53, 54, 55). Later, 
when the ovum has occupied the entire uterine cavity, and is supported 
everywhere by the uterine walls, which occurs about the end of the 



Fig. 53. 



Fig. 54. 



Fig. 55. 






Fig. 53.— Formation of decidua. (The decidua is colored black, the ovum is represented as 
engaged between two projecting folds of membrane. (After Dalton.) 
Fig. 54.— Projecting folds of membrane grow up around the ovum. (After Dalton.) 
Fig. 55.— Showing ovum completely surrounded by the decidua reflexa. (After Dalton.) 



third month, the reflexa fuses with the vera, and the two membranes 
atrophy together. During the first three months, therefore, there is a 
free space within the uterine cavity between the vera and the reflexa. 
The decidua serotina plays an important part in the development of the 
placenta, and will be considered subsequently when we come to the 
development of that organ. 

We return now to the attachments of the human ovum at the earliest 
period concerning which we are possessed of exact observations — viz., 
the end of the first week. Leopold has described with great care a 
seven days' ovum, which he discovered by accident in a uterus removed 
for cancer of the cervix (Fig. 56). In this case the uterine mucosa 
was much thickened (5-8 mm.), especially around the ovum, which 
was enclosed completely within a fold of the membrane, so that we 
know that even at this early period the decidua reflexa is fully formed. 
It appears to be formed by folds of the mucosa which grow up around 
the ovum and meet over its free pole, so as to completely invest it. 
From Leopold's illustration (see Fig. 57) it is apparent that the reflexa 
and chorion are separated by a considerable space, except at the two 



HO PREGNANCY. 

poles of the ovum ; at the attached pole a serotinal process is in direct 
contact with the chorion, and at the free pole, where there are no villi, 
chorion and reflexa are united over a considerable area. The space 
thus resulting (chorio- decidual space) is occupied by the chorionic villi, 
which are seen in longitudinal transverse, or oblique section in the 
drawing (Fig. 57). Most of the vili are free ; some are attached to 
the decidua by their tips, and others have penetrated it deeply, and are 
seen in cross-section imbedded in decidual tissue. Around the villi are 
masses of red and white blood-corpuscles, and one or two delicate cap- 
illaries are seen opening through the serotina into the chorio-decidual 
space. At a somewhat later period (end of second week), as Leopold 
has shown in a second case, the whole surface of the chorion is beset 
with villi, and the chorio-decidual space is continuous around the entire 
ovum. 

Fig, 56. 




i 






m 

of- i 






r ■* 




i 

Human ovuin in situ ; end of first week. o.i. Os internum. The decidual formation is seen to 
be confined to the body of the uterus. The ovum is implanted upon the posterior wall a little 
below the fundus. (After Leopold.) 

Chorionic Villi. — These points are of great interest and importance. 
They indicate that at this early period chorionic villi are found attached 
to the highly vascular decidual membrane, which entirely surrounds 
the ovum, while blood is poured out into the inter-villous spaces, thus 
bringing the foetal tissues into direct contact with the maternal blood. 
A simple form of placentation is thus established, which by the end of 
the second week involves the whole superfices of the ovum, thus cor- 
responding to the diffused placenta of the sow, the mare, the cetacea, 
etc. In Leopold's first case traces of vascularization were found in 



CONCEPTION AND GENERATION. 



Ill 



some, but not all of the villi, and it is probable, therefore, that the 
foetal circulation is at this stage incomplete, and transference of nutri- 
ment by osmosis from the maternal to the foetal blood-currents cannot 
occur ; but doubtless the villi are able to absorb directly from the ma- 
ternal blood without the aid of an active circulation. In the mammalia 
generally the umbilical vesicle plays an unimportant part in the nutri- 
tion of the embryo, and early provision is therefore made for the trans- 
mission of nutrient materials from the maternal blood. This provision 
is found in man in the simple form of placenta just described, and by it 
time is gained for the development of the more highly specialized dis- 



Fig. 57. 



D.v.{ 



Comp. 




Section through ovum and uterine wall ; end of first week. D.v. Decidua vera. Comp. Com- 
pact layer. Amp. Ampullary layer. M. Muscular wall of uterus. D.c. Decilua capsularis 
(renexa). b.b. Wall of ovum (chorion), a. Structureless remains of embryonic area. c.c. Chori- 
onic villi, d. Serotinal process to which ovum is attached, e. maternal vessel opening into 
chorio-decidual space. /. Chorionic villi imbedded in decidua. (After Leopold.) 

coidal placenta characteristic of man and some of the mammals. Its 
development consists simply in the specialization of a part of the 
chorion to do the work which in the earlier stages is done by the whole. 
At the placental site the villi increase very much in size, in number, 
and in the complexity of their branchings ; at the same time important 
changes, soon to be described, occur in the underlying serotina. By 
the end of the sixth week the placenta is well outlined. As it develops, 
the villi covering the general chorionic surface atrophy and become 
devascularized, and by the eighth week this process is nearly com- 



112 PREGNANCY. 

pleted. A diminution in the total area of the placenta is thus compen- 
sated by the specialization of a part of it. 

Nutrition of the Early Ovum. — It is therefore possible to account 
in a fairly satisfactory manner for the nutrition of the ovum from the 
end of the first week onward. We are still without information as to 
the precise period at which villi first appear on the human chorion, or 
the precise period at which these structures first come into relation 
with the maternal tissues. There is reason to believe, however, that 
villi first appear on the pole of attachment, and here the union of foetal 
and maternal tissues may follow very quickly upon implantation. 
Whence may come the force which carries the ovum through the first 
few days of its development before the formation of the chorion is one 
of the unsolved problems of biology. 

Formation of the Placenta. — We pass now to the consideration 
of the placenta, the mode of formation of which has just been briefly 
indicated. It corresponds to the pole of attachment of the ovum, and 
is usually formed around the point at which the ventral stalk, with its 
umbilical vessels, joins the chorion. The portion of the chorion con- 
cerned in the formation of the placenta is often called the chorion fron- 
dosum ; the extra-placental portion the chorion Iceve. The latter was 
so called because it was once thought to be non-villous, but as we have 
seen in the earlier stages, villi are equally distributed over all parts of 
the chorion, and it is only by the disappearance of its villi that the 
extra-placental portion becomes converted into a smooth membrane. 
The chorion f rondosum forms the foetal portion of the placenta ; it con • 
sists of a membrane underlying the amnion, with branching structures, 
called villi, springing from it; the structure of both membrane and 
villi is essentially the same. As the later months of gestation are 
reached the placenta undergoes many notable changes ; we shall there- 
fore consider first the early, and then the late placenta, and in both we 
must consider separately the foetal and maternal elements. 

The Early Placenta. Fcetal Elements. — At the end of the second 
month the foetal placenta consists of a dense forest of tree-like struc- 
tures, with many complicated branchings, growing out of the wall of 
the ovum. These are the chorionic villi ; their ramifications are quite 
irregular in size, shape, and direction. The final divisions (terminal 
villi) are more or less club-shaped structures, with a constricted base 
of attachment. The villi occupy the chorio-decidual space, but there 
are wide intervals between them, forming the system of inter-villous 
spaces, through which the maternal blood flows. Many of the villi 
are attached to the serotina by their tips, some penetrate it for a con- 
siderable distance, but the bulk of them are free. The membranous 
portion of the placental chorion limits the system of inter-villous 
spaces toward the ovum. The placental chorion consists of the follow- 
ing structures: (1) au epithelial covering; (2) a connective-tissue 
stroma ; (3) a system of bloodvessels. 

1. The chorionic epithelium clothes the outer (uterine) surface of the 
chorionic membrane and villi. As to its structure aud derivation there 
has been, and still exists, great diversity of opinion. Certain facts are, 
however, well established. It consists of two distinct layers : an outer 



CONCEPTION AND GENERATION, 



113 



layer of multi-nucleated protoplasm or plasmodiurn, in which no cell 
outlines can be distinguished, aud which is not therefore a truly cellular 
layer, and a deep (inner) layer of large well-defined cells with oval 
nuclei. The former may be called the plasmodial, the latter the cellular 
layer. It is probable that both these layers arise in the foetal epiblast, 
although there is an important school of German embryologists who 
hold that the plasmodial layer is maternal in origin, aud is derived 
from the uterine epithelium. This question, however, cannot be dis- 
cussed here. During the early months the plasmodial layer shows 
signs of great activity. From it spring numerous buds, elongated or 
club-shaped, conical or rounded, and having the same structure as the 
layer from which they arise. They are called the plamodial buds, and 
represent the first stage in the formation of new villi from old ones. 
The protoplasm of these buds is freely vacuolated, and the stroma soon 
grows into them, carrying with it connective tissue and bloodvessels, 
thus completing the structure of the new villus, and bringing it into 
connection with the foetal circulation through the placenta. All the 
stages of this process may be traced in a young placenta. 

2. The stroma is a delicate reticulum of connective tissue supporting 
the bloodvessels. In the larger divisions of the chorion it is more 
compact, resembling loose fibrous tissue, aud this is especially well 
marked around the largest arteries. The interstices of the reticulum 
form a system of anastomosing channels, probably of the nature of 
lymphatics. 



Fig. 58. 




Leaf-shaped villus of human placenta, showing wide capillaries packed with blood-corpuscles. 

(After Eden.) 



3. The bloodvessels are the terminal ramifications of the umbilical 
arteries and veins ; they pass into every division of the chorion frond o- 
sum, and in an injected placenta a delicate thread may often be traced 
passing into a plasmodial bud which has just become vascularized. 
In the larger divisions the vessels lie in the axis ; arteries and veins 
run side by side, the latter being distinguished by their thinner walls 



114 PREGNANCY. 

and larger calibre. In the terminal villi capillaries alone are found ; 
they are placed for the most part immediately beneath the epithelium, 
where they run a tortuous course and anastomose freely (Fig. 58). 
They are wide channels, iu which five or six red corpuscles lie abreast, 
and they occupy such a large extent of the stroma that the villus ap- 
pears to be as full of blood as a soaked sponge. The capillary walls 
consist of a single layer of delicate endothelium, and nothing intervenes 
between them and the maternal blood in the inter- villous spaces except 
the chorionic epithelium. 

Maternal Elements. — The part which is played by the decidua 
serotina in the development of the placenta is an important one. In 
the first place it is the medium through which the maternal circulation 
through the inter- villous spaces becomes established, and in the second 
place it serves to attach the fcetal elements firmly to the uterine wall. 
The steps by which the maternal placental circulation becomes estab- 
lished have not been quite fully made out, but enough is known to 
give some account of the process. 

The remarkable activity of the chorionic villi has been already 
referred to, and we have now to add that they are the chief agents in 
the production of the changes which result in the establishment of the 
inter-villous circulation. Early in the second month the young villi 
invade the serotinai tissues, boring their way deeply into the mem- 
brane ; they do not enter the glands, as was once supposed, but pene- 
trate the tissues by literally eating their way through. The plasmodial 
buds act as the pioneers of the invasion ; in Fig. 57 numbers of them 
may be seen imbedded in the decidual tissues. In its new position the 
bud becomes a villus in the manner already indicated, and this in turn 
throws off new buds, by which the advance is continued. Around the 
invading buds the decidual cells necrose and become absorbed (Bumm 1 ), 
the fcetal epiblast appearing to exert some potent destructive action 
upon them. These changes occur most markedly in the compact layer 
of the serotina, the deep layer being in the main free from the inva- 
sion ; but occasionally plasmodial buds or villi are found to have bored 
their way right through into the uterine musculature. In sections of 
the young serotiua these isolated buds have the appearance of giant 
cells (masses of protoplasm containing several nuclei), and w 7 ere for- 
merly regarded as derived from the decidual cells ; they are, however, in 
reality masses of fcetal epiblast. 

While the iuvasion of the serotina is proceeding, large hemorrhages 
appear in the membrane; these are formed in part by extension and 
fusion of the smaller ones already referred to as occurring in the early 
decidua, but many of them are produced by the invading villi, which 
eat their way through the walls of the vessels, capillaries, or larger 
vessels, thus laying them open and leading to fresh extravasation. In 
Fig. 59 a large blood-pool or lacuna is seen, in which are numbers of 
these buds and villi. By a process of extension toward the ovum these 
hemorrhages come to open into the chorio-decidual space, and the blood 
is then free to make its way among the villi. The larger lacuna? can 

i Archiv fur Gynakol., 1893. Ueber die Entwickelung des mutterlichen Kreislaufes in der mensch- 
lichen Placenta. 



CONCEPTION AND GENERATION, 



115 



ofteu be shown to have an artery and one or two venous channels com- 
municating directly with them. At this point observation has hitherto 
broken down, but the step from lakes of blood opening into the inter- 
villous spaces on the one hand, and communicating on the other with 








5= Mfc 



Section through a normal seven months' placenta in situ. Am. Amnion. Cho. Chorion. Vi. 
Primary villus, vessels injected, vi. Smaller villi. Ve. Maternal vein opening into inter-villous 
epaces. D. Decidua serotina. Mc. Muscular wall of uterus. (After Mixot.) 



maternal arteries and veins, to a direct circulation of maternal blood 
through the inter-villous spaces, is neither far nor difficult. Certainly 
it is a comparatively easy matter to show that in a well-formed placenta 
maternal arteries and veins open directly into the inter-villous spaces 



116 



PREGNANCY, 



upou the serotinal surface (Fig 59). To Waldeyer 1 belongs the credit 
of first demonstrating the fact by injecting the uterine arteries and veins 
in the cadaver of a pregnant woman. But their course can often be 
readily traced by microscopic examination of portions of placenta cut 
up in serial sections. The arteries preserve their characteristic coiling 
course through the serotina, and then open somewhat abruptly into the 
spaces ; the veins run an oblique course and open by long oblique 
mouths. Arterial may be distinguished from venous openings (1) by 
the thickness of their walls, (2) by the direction of the opening, (3) by 
the fact that villi are drawn, by the direction of the blood-current, into 
the mouths of the veins, while by the same force they are washed away 
from the mouths of the arteries. 

The precise period at which the maternal circulation is established 
is not known, but it is probably in existence early in the second month, 
becoming gradually completed as arteries and veins are thrown into 
communication with the inter-villous space. It is doubtful if there is 
any true maternal circulation through the temporarily diffused placenta ; 
the villi probably simply extract nutriment from the effused blood. In 
quite young ova there is a good deal of clotting in the chorio-decidual 
space, as is evidenced by the comparatively large deposits of fibrin 
found in it. 

Fig. 60. 




Scheme of placental attachments. Am. Amnion. Ch. Chorion. V Villi. S. Decidua serotina. 
D.Sc. Sub-chorionic decidua. V v Villi attached to serotina. A. Maternal artery. V 2 . Maternal 
vein. (After Eden.) 

While these changes are in progress the ovum is held to the uterine 
wall chiefly by the decidua reflexa. Later on the placenta becomes 
firmly united to the uterus, and constitutes the main attachment of 
the ovum. The delicate character of its early attachments is an im- 
portant factor in determining the frequency with which abortion occurs 
at this period ; when the placenta is fully formed the ovum is much 



1 Abhandl. d. k. Akademie der Wissenschaft zu Berlin, 1887. 



CONCEPTION AND GENERATION. 117 

less easily detached (Fig. 60). The foetal and maternal placental struc- 
tures are united by the following means : (1) Many villi become im- 
bedded in the serotina, and are actually fused with it by cell inter- 
growth ; (2) processes of the serotina grow up among the villi, some- 
times reaching as far as the chorionic membrane, and mauy villi are 
united to them ; (3) from the serotinal margin (line of origin of the 
reflexa) a process of serotinal tissue grows toward the centre of the 
placenta in contact with the outer surface of the chorionic membrane, 
and at term can be traced for one to two inches ; this is called the 
sub-ehorionic decidua ; it is continuous arouud the whole placental cir- 
cumference, and serves to strengthen the placental attachments where 
they are weakest, and also to limit circumferentially the general system 
of inter-villous spaces through which the maternal blood flows. 

The circulation through the inter-villous spaces is probably not a 
rapid one. The coiling course of the uterine arteries diminishes the 
force of the blood stream, and therefore the vis a tergo in the spaces ; 
the outflow from the spaces is largely promoted by the intermittent 
uterine contractions, which have the effect of aspirating their contents 
into the veins. A slow current is probably an advantage in allowing 
time for osmotic interchanges. 

Inter-villous Spaces. — We must now refer for a moment to the 
question of the origin of the inter-villous spaces, around which so 
many rival theories have gathered in the past. From the above de- 
scription of the development of the placenta it follows that they are 
extra-vascular spaces, formed mainly from the early ehorio-decidual 
space, which has been thrown into communication with the maternal 
circulation by the agency of the chorionic villi. This view, it will be 
remembered, is based upon recent observation, and is not speculative, 
like many of the older theories. 

The early view that there is a direct interchange of blood between 
the foetus and the mother is, of course, negatived by anatomical facts ; 
there is no provision whatever for such an interchange. Some ob- 
servers, and notably Braxton Hicks 1 have altogether denied the exist- 
ence of a circulation through the inter-villous spaces, but this view is 
now quite as untenable as the previous one. Many observers have 
regarded the spaces as modifications of maternal bloodvessels. Turner 2 
and Ercolani 3 first advanced this view, which twenty years ago was 
generally accepted, and more recently it has been revived in a some- 
what modified form by Waldeyer. 4 According to these observers the 
spaces are everywhere enclosed in maternal tissues ; they therefore 
regard the villi as foetal structures provided with a covering of maternal 
tissue, and this covering they find in the superficial layer of the chori- 
onic epithelium. According to Turner and Ercolani this layer repre- 
sents the altered walls of the maternal vessels, while the cellular layer 
beneath it is the foetal epiblast. Waldeyer's view is somewhat different. 
He asserts that he has discovered a third layer covering the villi, situ- 
ated upon the plasmodial layer and consisting of a very delicate endo- 

1 Transactions Obstetrical Society of London. 1873. 

2 Lectures on the Comparative Anatomy of the Placenta. First series, 1876. 

3 The Utricular Glands of the Uterus. Translation, 1880. 

4 Archiv fur microscopische Anatomie, 1^'jO. 



118 PKEGNANCY. 

thelium, which he believes to represent the walls of the dilated maternal 
capillaries from which the spaces are developed. Into these enormously 
dilated capillaries he says the villi dip, investing their walls, but not 
pierciug them. No one else has ever discovered Waldeyer's endothe- 
lial layer, and none of these three observers has traced the stages by 
which the maternal vessels become the inter-villous spaces. Their 
views are speculative, and are based upon the erroneous premise that 
a double layer composed of both foetal and maternal tissue intervenes, 
in the placenta, between the foetal and maternal blood-currents. 

Functions of the Placenta. — The placenta is the vehicle through 
which the fsetal processes of oxygenation and nutrition are carried on ; 
in the early months of embryonic life it is also the sole channel of ex- 
cretion ; later on the skin and kidneys take over the excretory func- 
tions. The completed placental scheme presents an arrangement 
admirably adapted to promote osmotic interchanges between the foetal 
and maternal blood-currents, the chorionic epithelium representing the 
dialyzer. It is probable that the placenta is merely the vehicle of these 
interchanges, and is not in any sense a glandular or secreting organ. 
Some years ago the theory was much in vogue that the serotinal glands 
secreted a nutrient fluid termed u uterine milk," which was absorbed 
by the villi and supplied the foetal organism with much of the nutri- 
ment it required. This view has, however, never been adequately 
supported by facts, and is now discarded. 

The actual facts regarding the placental interchanges are very scanty. 
From comparative analyses of the blood flowing to and leaving the 
placenta by the umbilical vessels, we know that the foetal blood takes 
up O and throws off C0 2 in its passage through the organ, that is to 
say, the foetus respires through its placenta. About the nutritional 
interchanges practically nothing is known. It is easy to understand 
how diffusible substances, such as water, salts, sugar, peptones, etc., 
may pass through the dialyzer, but how the foetus obtains its supplies 
of indiffusible substances, such as fat, we do not know. Experiment 
has taught us that various gaseous and soluble solid substances may be 
passed through the placenta to the foetus, but all attempts to transfer 
finely divided insoluble solids from the maternal blood to the foetus 
have broken down. It is held by many that certain pathogenic organ- 
isms, such as streptococci, staphylococci, etc., may pass through, and 
directly transfer the disease from mother to foetus, but even on this 
point the results obtained hitherto are not free from objection. The 
transference of disease is, of course, not open to doubt, but it is ques- 
tionable whether the orgauisms themselves pass over. There is also 
no evidence to show that any transference of the cellular elements of 
the blood occurs in the placenta. 

In what manner the foetus makes use of the tissue-forming materials 
brought to it is also unknown. The hemopoietic organs are markedly 
developed, and it is possible they play an important part in the elabora- 
tion of the crude materials brought to them. Glycogen was discovered 
in the placenta by Claude Bernard, and it has recently been shown 
that this substance may always be found in the cells of the serotina. It 
no doubt plays some part in nutrition, but that part is quite unknown. 



CONCEPTION AND GENERATION. 119 

Mode of Growth of the Placenta. — The placenta grows very 
rapidly daring the first few weeks after its formation ; it encroaches 
more and more upon the uterus, until by the end of the third month 
it occupies one-fourth of the total uterine surface. At this period the 
ovum fills the entire uterine cavity, and is directly supported by its 
walls, while the vera and reflexa are in apposition. From this point 
uterus and ovum grow pari passu, and the proportion of one-fourth 
is preserved up to term. The placenta is limited at its margin by the 
line of reflection of the decidua upon the ovum. Previous to the end 
of the third month this line of reflection moves with the growth of the 
placenta, passing further and further outward to enclose an ever-in- 
creasing area. During this period, therefore, the reflexa grows with 
the ovum ; afterward it is unneeded for the support of the ovum, and 
becomes thinned and atrophied from pressure. The placenta, how- 
ever, continues to increase in size proportionately with the uterus, 
while in thickness it undergoes progressive increase within the area 
mapped out for it. 

The Chorion Lseve. — The atrophy of the extra-placental villi is 
chiefly due to the withdrawal of their blood-sapply consequent upon 
the development of the placenta. Somewhat later, when the ovum 
fills the uterus, the chorio-decidual space is obliterated by pressure, and 
the atrophied villi become surrounded by riugs of fibrin deposited by 
clotting from the maternal blood in this space. In this form the altered 
villi may always be found in tbe membranes of a young ovum, and 
they appear to be imbedded in the atrophied decidual tissue. Near 
the placental margin traces of them may often be found at term. 

The Amnion. — The structure of the amnion does not progress be- 
yond an early embryonic stage. It consists of a single layer of low 
cuboidal or sometimes columnar epithelium, resting upon a structure of 
loose connective tissue with wide meshes. It is easily stripped off the 
chorion lseve and the foetal surface of the placenta, up to the insertion 
of the umbilical cord. The fluid it contains is foetal in origin ; it is 
formed ab initio, in the blastodermic vesicle, by segregation from the 
foetal tissues ; after the development of the placenta it probably comes 
in great part by transudation from the vessels exposed upon the foetal 
surface ; in the latter months some may come through the skin, and 
certain observers have maintained that the foetal urine also finds its 
way into the liquor amnii. It is a clear, pale fluid of low specific 
gravity (1006 to 1008), alkaline in reaction, and consisting of 

Water 9S.41 

Albumin 0.19 

Inorganic salts 0.59 

Extractives 0.81 



100.00 



The ninst important "extractive" is urea, traces of which have 
been found by Prochownik as early as the sixth week ; in the last two 
months the amount is much larger, and is said to be directly propor- 
tional to the weight of the foetus. Its chief source is probably tha 
foetal skin. In the second half of pregnancy the liquor amnii contains 
various solid matters in suspension, chiefly skin products, such as 



1 20 PREGNANCY. 

lanugo, epidermal scales, and masses of vernix caseosa. The amount 
of fluid present varies very much ; toward the end of gestation it is 
seldom less than ten or more than fifty ounces (Ahlfeld). 

The function of the amniotic fluid is essentially protective. It dimin- 
ishes the risks of injury from without, equalizes pressure, allows free 
movements of the foetus, and in labor cleanses the passages by flushing 
them from within. Ahlfeld 1 has attempted to establish the liquor 
amnii as an important source of foetal nutrition. He believes that it 
is swallowed in considerable amount, and absorbed from the stomach 
into the circulation, thus supplying water, albumin, salts, etc. This 
view rests upon the observation that hair balls, composed of the short, 
woolly hairs of the foetal skin (lanugo), may sometimes be found on 
post-mortem examination in the stomach at birth; they can only have 
been produced by separation from liquor amnii received into the 
stomach in large amount, and considerable time is necessary for their 
formation. They therefore prove that in such cases liquor amnii has 
been swallowed by the foetus. But there is no evidence to show that 
these hair-balls exist in the stomachs of living healthy children, which 
should be the case were liquor amnii always employed by the foetus in 
this way. Aud in addition it is obvious, from its composition, that 
the fluid cannot be an important factor in nutritive processes. 

The Umbilical Cord. — The umbilical cord connects the foetus with 
its placenta. Developmentally it is formed from the ventral stalk, the 
allautois, the umbilical arteries (2) and veins (2), and the umbilical 
vesicle ; the ccelum or body cavity is also prolonged into it, and does 
not become finally shut off until the third or fourth month. The first 
of the early constituents to disappear is the umbilical vesicle, but traces 
of it may at times be found at term near the placental insertion of the 
cord ; then the ccelum closes, then the allautois disappears, and finally 
the two veins fuse to form a single channel, the arteries remaining dis- 
tinct. In the proximal end of the cord of a three months' foetus, traces 
of the allantois may often be found in the form of a narrow canal lined 
with polygonal cells of epithelial type. More rarely the prolongation 
of the ccelum persists as late as this, and may contain a coil of small 
intestine ; the condition known as exomphalos results from permanent 
non-closure of the ccelum. The substance of the cord consists of a 
loose connective tissue with wide interspaces filled with fluid ; it is 
called Wharton's jelly, and represents the mesoblastic tissue of the 
ventral stalk. It is covered with an epithelial layer, stratified in the 
early months, but single later on ; this is probably to be regarded as 
a modification of the foetal epidermis, and not as a prolongation of the 
amnion. (Minot.) At term the cord measures from eighteen to 
twenty-four inches, but in exceptional cases may be as short as five, or 
as long as sixty inches. The umbilical vessels are at first straight, but 
as the cord increases in length the arteries become twisted round the 
vein, and generally the twist is from left to right. There is no satis- 
factory explanation of the twisting of the cord. The vessels do not 
branch until they reach the placenta, and the veins have no valves, 

1 Lehrbuch der Geburtshulfe, 1894. 






CONCEPTION AND GENERATION. 121 

Small nodes or thickenings containing a vascular pouch are frequently 
found upon the cord ; they are spoken of as false knots. True knots 
sometimes form when the cord is unusually long, and the foetus slips 
through a loop of it. 

The Placenta at Term. —When shed from its uterine attachments 
the placenta is seen to be an oval or circular cake of spongy consistence 
measuring six to eight inches in diameter, and one to two inches in the 
thickest part, which is the centre. The margin is thinner and firmer 
than the centre, and passes somewhat abruptly into the chorion lgeve. 
The umbilical cord is attached to the foetal surface near the centre ; its 
insertion may, however, be excentric, or on the placental margin 
(battledore placenta) or upon the chorion at some distance outside the 
placental margin (velamentous placenta). These irregularities occur 
when the placenta is not equally developed around the attachment of 
the ventral stalk to the wall of the early ovum. 

The foetal surface is covered with the amnion, which may be stripped 
readily off as far as the insertion of the cord. Beneath it lie the sur- 
face branches of the umbilical vessels. The arteries divide at once 
upon reaching the placenta, and the divisions are often larger than the 
parent stem. They continue to branch irregularly as they approach 
the placental margin, but the terminal divisions never actually reach 
the edge. The veins accompany and often cross the arterial branches. 
The latter all plunge vertically into the placental tissue, then run for 
a short distance horizontally, then dip downward again, forming a 
terraced arrangement of steps in their course. Thus they pass into all 
the ramifications of the villi, and are closely accompanied by the veins. 
Upon the foetal surface may also be seen large numbers of small grayish 
or yellowish nodules, slightly elevated and seldom larger than half a 
split pea. On incising them it is seen that they are firm masses at- 
tached to the membranous part of the placental chorion. Their struc- 
ture will be referred to later. At times a tiny yellowish body may be 
found at the insertion of the cord between the chorion and amnion ; 
this is the remains of the umbilical vesicle. 

The uterine surface of the placenta is covered with a thin, grayish, 
mottled coat, which represents the shed portion of the serotina ; it is 
often incomplete in places, exposing the villi beneath. This surface 
usually feels rough and gritty, and often little calcareous plates can be 
detected upon it with the naked eye. It is divided by sulci into a 
variable number of more or less quadraugular areas called the placental 
cotyledons ; into these sulci the serotina dips, sometimes passing as far 
as the membranous chorion. The continuity of the serotina with the 
decidua vera at the placental margin can often be distinctly traced. But 
while it is easy to strip the decidua vera and reflexa off the chorion lseve, 
the serotina cannot be thus detached from the placenta, on account of 
the firm union of many of the villi with it. If the placenta be floated 
under water the torn ends of the coiling serotinal arteries may some- 
times be seen, and also the obliquely placed veins ; the arteries are gen- 
erally in the centre of a cotyledon, the veins at the periphery. 

When incised the cut surface of the placenta is seen to be of a dark, 
mottled purplish color, and traversed by numerous grayish strands, 



122 PREGNANCY. 

representing the larger-sized villi. From a cut placenta a great deal 
of blood slowly exudes ; most of this is maternal blood from the 
inter-villous spaces, which can be practically drained from a single 
incision. If a stream of water be turned upon the cut surface the 
spaces are washed out, and the arborescent villi then become evident, 
appearing as delicate grayish branching threads. 

The microscope shows that considerable changes have affected all the 
placental structures. It must be remembered that the placenta is a 
caducous orgau, that the foetal elements which constitute the great bulk 
of it never advance beyond the stage of embryonic structure, and that 
its life cycle is a short one. As terra approaches degenerative pro- 
cesses set in, which are not due to any definite pathological factor, but 
are comparable to the withering of a leaf before it is shed by the tree. 

Postal Structures. — Most of the villi have lost their early plump- 
ness, and appear smaller and more angular than those of a young 
placenta. Examined carefully these villi show marked atrophy of 
their epithelial covering. The deep layer has entirely disappeared, 
and the superficial layer is thinned and incomplete, so that they often 
present bare areas where the capillaries lie directly exposed to the blood 
in the inter-villous spaces. Further, the processes oi budding and 
formation of new villi described earlier are never present. It is quite 
possible by these signs to distinguish old placental villi from young 
ones. 

Fig. 61. 




Showing arterial changes in villus stem of normal placenta at term. The artery is nearly obliter- 
ated, while the vein remains unaffected. (After Eden.) 

The most important changes, however, affect the foetal arteries, the 
medium-sized divisions of which show marked endarteritis obliterans, 
leading at times to complete occlusion of considerable arterial tracts, 
and in all cases embarrassing the circulation through the villi supplied 
by them. The veins are almost unaffected by the process, and often a 
nearly obliterated artery may be seen side by side with a widely patent 
vein (Fig. 61). In the areas supplied by these vessels the villi there- 
fore suffer. Their epithelial coat first undergoes a peculiar form of 






PREGNANCY. 123 

coagulation necrosis termed fibrinous degeneration, and upon the 
necrosed area the maternal blood clots, forming heaps of fibrin adherent 
to the villi. As the necrosis and clotted blood extend, clusters of 
neighboring villi become fused together by masses of fibrin, and villi 
thus affected are of course funetionless, because they are cut off from 
the maternal blood. They rapidly atrophy, and ofien undergo fatty 
and calcareous degeneratiou. These changes occur as early as the end 
of the seventh month, and progress slowly up to term. In all ripe 
placentae numerous small areas of villi thus affected may be found with 
the microscope, and in most cases there are also scattered nodules large 
enough to be seen by the naked eye. These latter have been termed 
" white infarcts," from their naked-eye resemblance to old infarctions 
as found in the kidneys, spleen, etc. They occur most numerously 
upon the uterine surface and at the placental margin, and are readily 
recognized as firm yellowish white, well-defined areas which stand out 
in stroug contrast with the deep red spongy tissue around them. They 
vary in size from that of a pea to that of a filbert, and occasionally 
they may involve an entire marginal cotyledon. The small nodules 
seen upon the foetal surface when stripped of its amnion are either 
clumps of fibrin or small " infarcts." Before their nature was under- 
stood these " infarcts " were attributed to inflammation (placentitis), 
hemorrhage, fibro-fatty degeneration, etc., and were regarded as evi- 
dences of disease. They occur, however, in varying size and number 
in all healthy placentae, and are rather to be regarded as physiological 
degenerations. 

Maternal Structures. — The decidua serotina is thinned, and the 
compact layer extensively affected by a process similar to the " fibrinous 
degeneration " of the chorionic epithelium. It is probably due to the 
same cause, for Friedlander 1 and Minot 2 have shown that thrombosis 
occurs in the sub-placental venous sinuses during the last two or three 
months of gestation, and later on the coiling arteries themselves may 
become thrombosed. These changes not only interfere with the blood 
return from the placenta, but also interrupt the circulation through the 
vessels which supply the serotina. 

It is possible that in these degenerative changes affecting the placental 
structures so widely, we have one of the exciting causes of the onset of 
labor ; when the placenta begins to be unfit for its work the ovum is 
cast off. Separation occurs through the ampullary layer of the serotina, 
small portions of it remaining attached to the uterus at the placental 
site. It is important to note that there is no division of foetal from 
maternal elements ; when the organ is shed the greater part of the 
serotina goes with the placenta, aud the greater part of the vera with 
the membranes. From portions of the ampullary layer retained at 
the placental site aud elsewhere, the endometrium is regenerated in the 
puerperium. 

i Physiologisch-anatoniische Untersuchungen liber den Uterus. 1870. 2 Loc. cit. 



124 PREGNANCY. 

C PI AFTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 

It is obviously impossible to attempt anything like a full account 
of the development of the various foetal structures, or of their growth 
during mtra-uterine life. To do so would lead us far beyond the 
scope of this work, and would involve a study of complex details only 
suitable in a treatise on embryology. It is of importance, however, 
that the practitioner should have it in his power to determine approxi- 
mately the age of the foetus in abortions or premature labors, and for 
this purpose it is necessary to describe briefly the appearance of the 
foetus at various stages of its growth. 

1st Month. The foetus in the first month of gestation is a minute 
gelatinous and semi-transparent mass, of a grayish color, in which no 
definite structure can be made out, and in which no head or extremities 
can be seen. It is rarely to be detected in abortions, being lost in 
surrounding blood-clots. In the few examples which have been care- 
fully examined it did not measure more than a line in length. It is, 
however, already surrounded by the amnion, and the pedicle of the 
umbilical vesicle can be traced into the unclosed abdominal cavity. 

2d Month. The embryo becomes more distinctly apparent, and is 
curved on itself, weighing about sixty-two grains, and measuring six 
to eight lines in length. The head and extremities are distinctly vis- 
ible — the latter in the form of rudimentary projections from the body. 
The eyes are to be seen as small black spots on the side of the head. 
The spinal column is divided into separate vertebrae. The indepen- 
dent circulatory system of the foetus is now beginning to form, the 
heart consisting of only one ventricle and one auricle, from the former 
of which both the aorta and pulmonary arteries arise. On -either side 
of the vertebral column, reaching from the heart to the pelvis, are two 
large glandular structures, the corpora Wolffiana, which consist of a. 
series of convoluted tubes opening into an excretory duct, running 
along their external borders, and connected below with the common 
cloaca of the genito-urinary and digestive tracts. They seem to act as 
secreting glands, and fulfil the functions of the kidneys before they 
are formed. Toward the end of the second month they atrophy and 
disappear, and the only trace of them in the foetus at term is to be 
found in the parovarium lying between the folds of the broad liga- 
ments. At this stage of development there are met with in the human 
embryo, as in that of all mammals, four transverse fissures opening 
into the pharynx, which are analogous to the permanent branchiae of 
fishes. Their vascular supply is also similar, as the aorta at this time 
gives off four branches on each side, each of which forms a branchial 
arch, and these afterward unite to form the descending aorta. By the 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 125 

end of the sixth week these, as well as the transverse fissures to which 
they are distributed, disappear. By the end of the second month the 
kidneys and supra -renal capsules are forming, and the single ventricle 
is divided into two by the growth of the inter-ventricular septum. 
The umbilical cord is quite straight, and is inserted into the lower 
part of the abdomen. Centres of ossification are showing themselves 
in the inferior maxillary bones and the clavicle. 

3d Month. The embryo weighs from seventy to three hundred 
grains, and measures from two and a half to three and a half inches 
in length. The forearm is well formed, and the first traces of the 
fingers can be made out. The head is large in proportion to the rest 
of the body, and the eyes are prominent ; the mouth is closed by the 
lips, and is separated by them from the nasal cavity. The umbilical 
vesicle and allantois have disappeared, and the alimentary canal is 
now situated entirely within the abdominal cavity. The greater 
portion of the chorion villi have atrophied, and the placenta is 
distinctly formed. 

4th Month. The weight is from four to six ounces, and the length 
about six inches. The convolutions of the brain are beginning to 
develop. The sex of the child can now be ascertained on inspection. 
Hairs begin to be formed on the head. The muscles are sufficiently 
formed to produce distinct movements of the limbs. Ossification is 
extending, and can be traced in the occipital and frontal bones, and in 
the mastoid processes. The sexual organs are differentiated. 

6th Month. Weight about ten ounces. Length, nine or ten inches. 
Hair is observed covering the head, which forms about one-third of 
the length of the Avhole foetus. The nails are beginning to form, and 
ossification has commenced in the ischium. The foetal movements are 
distinct, and in cases of premature delivery, may continue for some 
time after the birth of the child. 

6th Month. Weight about one pound. Length, eleven to twelve 
and a half inches. The hair is darker. The eyelids are closed, and 
the membrana pupillaris exists; eyelashes have now been formed. 
Some fat is deposited under the skin. The testicles are still in the 
abdominal cavity. The clitoris is prominent. The pubic bones have 
begun to ossify. 

7th Month. Weight from three to four pounds. Length, thirteen 
to fifteen inches. The skin is covered with unctuous, sebaceous matter, 
and there is a more considerable deposit of subcutaneous fat. The 
eyelids are open. The testicles have descended into the scrotum. 
Children born at this time may occasionally survive. 

Sth Month. Weight from four to five pounds. Length, sixteen to 
eighteen inches, and the foetus seems now to grow in thickness rather 
than in length. The nails are completely developed. The membrana 
pupillaris has disappeared. 

Foetus at Term. — At the completion of pregnancy the foetus weighs 
on an average, six and a half pounds, and measures about twenty 
inches in length. These averages are, however, liable to great varia- 
tion. Remarkable histories are given by many writers of foetuses of 
extraordinary weight, which have been probably greatly exaggerated. 



126 PE EG NANCY. 

Out of 3000 children delivered under the care of Cazeaux at various 
charities, one only weighed ten pounds. There are, however, several 
carefully recorded instances of weight far exceeding this ; but they are 
undoubtedly much more uncommon than is generally supposed. Dr. 
Ramsbottom mentions a foetus weighing sixteen and a half pounds ; 
Cazeaux tells us of one which he delivered by turning, which weighed 
eighteen pounds and measured two feet one and a half inches; and 
the birth of one weighing twenty-one pounds has been recently 
recorded. 1 Such overgrown children are almost invariably stillborn. 2 

The average size of male children at birth, as in after-life, is some- 
what greater than that of female. Thus Simpson 3 found that out of 
100 cases the male children averaged ten ounces more in weight than 
the female, and half an inch more in length. 

A newborn child at term is generally covered to a greater or less 
extent with a greasy, unctuous material, the vernix caseosa, which is 
formed of epithelial scales and the secretion of the sebaceous glands, 
and which is said to be of use in labor by lubricating the surface of 
the child. The head is generally covered with long dark hair, which 
frequently falls off or changes in color shortly after birth. Dr. Wilt- 
shire 4 has called attention to an old observation, that the eyes of all 
newborn children are of a peculiar dark steel-gray color, and that 
they do not acquire their permanent tint until some time after birth. 
The umbilical cord is generally inserted below the centre of the 
body. 

Anatomy of the Foetal Head. — The most important part of the 
foetus from an obstetrical point of view is the head, which requires a 
separate study, as it is the usual presenting part, and the facility of 
the labor depends on its accurate adaptation to the maternal passages. 

The chief anatomical peculiarity of interest, in the head of the foetus 
at term, is that the bones of the skull, especially of its vertex — which, 
in the vast majority of cases, has to pass first through the pelvis — are 
not firmly ossified as in adult life, but are joined loosely together by 
membrane or cartilage. The result of this is that the skull is capable 
of being moulded and altered in form to a very considerable extent by 
the pressure to which it is subjected, and thus its passage through the 
pelvis is very greatly facilitated. This, however, is chiefly the case 
with the cranium proper, the bones of the face and of the base of the 
skull being more firmly united. By this means the delicate structures 
at the base of the brain are protected from pressure, while the change 
of form which the skull undergoes during labor implicates a portion 
of the skull where pressure on the cranial contents is least likely to be 
injurious. 

i Brit. Med. Journ., Feb. 1, 1879. 

2 Probably the largest fetus on record was that of Mrs. Captain Bates, the Nova Scotia giantess, 
a woman of seven feet nine inches, whose husband is also of gigantic build, reaching seven feet 
seven inches in height. This child, born in Ohio, was their second, and was lost in its birth, as 
no forceps could be procured of sufficient size to grasp the head. The foetus weighed twenty-three 
and three-quarter pounds, and was thirty inches in length. Their first infant weighed nineteen 

Sounds. We have had children born in this city (Philadelphia) at maturity and live, that weighed 
ut one pound. The well-remembered " Pincus baby" weighed a pound and an ounce. (Harris,, 
note to 3d American edition). „ , _ „_., 

a Selected Obstetrical Works, p. 327. 4 Lancet, February 11, 18/1. 



ANATOMY AND PHYSIOLOGY OF THE FCETCJS. 



127 



The divisions between the bones of the cranium are further of 
obstetric importance in enabling us to detect the precise position of the 
head during labor, and an accurate knowledge of them is therefore 
essential to the obstetrician. 

AVe talk of them as sutures and fontanelles: the former being the 
lines of junction between the separate bones, which overlap each other 
to a greater or less extent during labor ; the latter, membranous inter- 
spaces where the sutures join each other. 

The principal sutures are: 1st. The sagittal, which separates the 
two parietal bones, and extends longitudinally backward along the 
vertex of the head. 2d. The frontal, which is a continuation of the 
sagittal, and divides the two halves of the frontal bone, at this time 
separate from each other. 3d. The coronal, which separates the frontal 
from the parietal bones, and extends from the squamous portion of the 
temporal bone across the head to a corresponding point on the opposite 
side. 4th. The lambdoidal, which receives its name from its resem- 
blance to the Greek letter A, and separates the occipital from the 
parietal bones on either side. The fontanelles (Fig. 62) are the mem- 
branous interspaces where the sutures join — the anterior and larger 
being lozenge-shaped, and formed by the junction of the frontal, 
sagittal, and two halves of the coronal sutures. It will be well to note 
that there are, therefore, four lines of sutures running into it, and four 
angles, of which the anterior, formed by the frontal suture, is most 
elongated and well marked. The posterior fontanelle (Fig. 63) is 
formed by the junction of the sagittal suture with the two legs of the 
lambdoidal. It is, therefore, triangular in shape, with three lines of 
sutures entering it in three angles, and is much smaller than the an- 
terior fontanelle, forming merely a depression into which the tip of the 
finger can be placed, while the latter is a hollow as big as a shilling, 
or even larger. As it is the posterior fontanelle which is generally 



Fig. 62. 



Fig. 63. 





Anterior and posterior fontanelles. 



Bi-parietal diameter, sagittal and 
lambdoidal sutures, with posterior 
fontanelle. 



lowest, and the one most commonly felt during labor, it is important 
for the student to familiarize himself with it, and he should lose no 



128 



PREGNANCY. 



Fig. 64. 



opportunity of studying the sensations imparted to the finger by the 
sutures and fontanelles in the head of the child after birth. 

The Diameters of the Fcetal Skull. — For the purpose of under- 
standing the mechanism of labor, we must study the measurements of 

the fcetal head in relation to the 
cavity through which it has to 
pass. They are taken from corre- 
sponding points opposite to each 
other, and are known as the 
diameters of the skull (Fig. 64). 
Those of most importance are : 
1st. The occipito-mentalis (o.m), 
from the occipital protuberance to 
the point of the chin, 5.25" to 
5.50". 2d. The occipito-frontalis 
(o.f), from the occiput to the 
centre of the forehead, 4. 50" to 
5". 3d. The sub-occipito-breg- 
matica (s. o. b), from a point mid- 
way between the occipital pro- 
tuberance and the margin of the 
foramen magnum to the centre of 
4th. The cervico-bregmatica (c. b), from 




1—2. Diameter occipito-frontalis (o.f). 
3 — 4. " occipito-mentalis (o.m). 

5—6. " cervico-bregmatica (c.B). 

7—8. " fronto-mentalis (f.m). 

the anterior fontanelle, 3.25". 



the anterior margin of the foramen magnum to the centre of the 
anterior fontanelle, 3.75". 5th. Transverse, or bi-parietalis (bi-p), 
between the parietal protuberances, 3.75" to 4". 6th. Bi-temporalis 
(bi-t), between the ears, 3.50". 7th. Fronto-mentalis (f.m), from the 
apex of the forehead to the chin, 3.25". 

The length of these respective diameters, as given by different 
writers, differs considerably — a fact to be explained by the measure- 
ments having been taken at different times ; by some just after birth, 
when the head was altered in shape by the moulding it had undergone ; 
by others when this had either been slight, or after the head had 
recovered its normal shape. The above measurements may be taken as 
the average of those of the normally shaped head, and it is to be 
noted that the first two are most apt to be modified during labor. The 
amount of compression and moulding to which the head may be sub- 
jected, without proving fatal to the foetus, is not certainly known, but 
it is doubtless very considerable. Some interesting examples of the 
extent to which the head may be altered in shape in difficult labors 
have been given by Barnes, 1 who has shown by tracings of the shape 
of the head taken immediately after delivery, that in protracted labor 
the occipito-mental (o. m) and occipito-frontal (o. f) diameters may be 
increased more than an inch in length, while lateral compression may 
diminish the bi-parietal (bi-p) diameters to the same length as the 
inter-auricular. The fcetal head is movable on the vertical column to 
the extent of a quarter of a circle ; and it seems probable that the 
laxity of the ligaments admits with impunity a greater circular move- 
ment than would be possible in the adult. 



i Obst. Trans., 1SGG, vol. vil. p. 171. 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 129 

On taking the average of a large number of measurements, it is 
found that the heads of male children are larger and more firmly 
ossified than those of females, the former averaging about half an 
inch more in circumference. Sir James Simpson attributed great 
importance to this fact, and believed that it was sufficient to account 
for the larger proportion of stillbirths in male than in female chil- 
dren, as well as for the greater difficulty of labor and the increased 
maternal mortality that are found to attend on male births. His 
well-known paper on this subject, which has given rise to much con- 
troversy, is full of the most elaborate details, and so great did he 
believe the foetal influence to be, that he calculated that between 
the years 1834 and 1837 there were lost in Great Britain, as a conse- 
quence of the slightly larger size of the male than of the female head 
at birth, about 50,000 lives, including those of about 46,000 or 47,000 
infants, and of between 3000 and 4000 mothers who died in childbed. 1 
It is probable that race and other conditions, such as civilization and 
intellectual culture, have considerable influence on the size of the foetal 
skull, but we are not in possession of sufficiently accurate data to jus- 
tify any very positive opinion on these points. 

In the very large majority of cases the foetus lies in utero with head 
downward, and is so placed as to be adapted in the most convenient 
way to the cavity in which it is placed. The uterine cavity is most 
roomy at the fundus, and narrowest at the cervix, and the greatest 
bulk of the foetus is at the breech, so that the largest part of the child 
usually lies in the part of the uterus best adapted to contain it. The 
various parts of the child's body are, further, so placed in regard to 
each other as to take up the least possible amount of space. (See 
Plates I., IH.) The body is beat so that the spine is curved with its 
convexity outward, this curvature existing from the earliest period of 
development: the chin is flexed on the sternum ; the forearms are 
flexed on the arms, and lie close together on the front of the chest; 
the legs are flexed on the thighs, and the thighs drawn up on the abdo- 
men ; the feet are drawn up toward the legs ; the umbilical cord is 
generally placed out of reach of injurious pressure, between the arms 
and the thighs. Variations from this attitude, however, are not un- 
common, and are not, as a rule, of much consequence. Although the 
cranial presentations are much the most common, averaging 86 out of 
every 100 cases, other presentations are by no means rare, the next 
most frequent being either that of the breech, in which the long 
diameter of the child lies in the long diameter of the uterine cavity ; or 
some variety of transverse presentation, in which the long diameter of 
the foetus lies obliquely across the uterus, and no longer corresponds 
to its longitudinal axis. 

It was long believed that the head presentation was only assumed 
toward the end of pregnancy, when it was supposed to be produced 
by a sudden movement on the part of the foetus, known as the culbute. 
It is now well known that in the large majority of cases, the head is 
lowest during all the latter part of pregnancy, although changes in 

i Selected Obst. Works, p. 363. 
9 



130 PREGNANCY. 

position are more common than is generally believed to be the case, 
and presentation of parts other than the head is much more frequent 
in premature labor than in delivery at term. In evidence of the last 
statement, Churchill says that in labor at the seventh month the head 
presents only 83 times out of 100 when the child is living, and that 
as many as 53 per cent, of the presentations are preternatural when 
the child is stillborn. The frequency with which the foetus changes 
its position before delivery has been made the subject of investigation 
by various German obstetricians, and the fact can be readily ascertained 
by examination. Valenta 1 found that out of nearly 1000 cases, care- 
fully and frequently examined by him, in 57.6 per cent, the presenta- 
tion underwent no change in the latter months of pregnancy, but in 
the remaining 42.4 per cent, a change could be readily detected. 
These alterations were found to be most frequent in multipara?, and 
the tendency was for abnormal presentations to alter into normal ones. 
Thus it was common for transverse presentations to alter longitudinally, 
and but rare for breech presentations to change into head. The ease 
with which these changes are effected no doubt depends, in a con- 
siderable degree, on the laxity of the uterine parietes, and on the 
greater quantity of amniotic fluid, by both of which the free mobility 
of the foetus is favored. 

The facility with which the position of the foetus in utero can be 
ascertained by abdominal palpation has not been generally appreciated 
in obstetric works, and yet, by a little practice, it is easy to make it 
out. Much information of importance can be gained in this way, and 
it is quite possible, under favorable circumstances, to alter abnormal 
presentations before labor has begun. For the purpose of making 
this examination, the patient should lie at the edge of the bed, Avith 
her shoulders slightly raised, and the abdomen uncovered. The first 
observation to make is to see if the longitudinal axis of the uterine 
tumor corresponds with that of the mother's abdomen ; if it does, the 
presentation must be either a head or a breech. By spreading the 
hands over the uterus (Fig. 65), a greater sense of resistance can be 
felt, in most cases, on one side than on the other, corresponding to the 
back of the child. By striking the tips of the fingers suddenly inward 
at the fundus, the hard breech can generally be made out, or the head 
still more easily, if the breech be downward. When the uterine walls 
are unusually lax, it is often possible to feel the limbs of the child. 
These observations can be generally corroborated by auscultation, for 
in head presentations the foetal heart can usually be heard below the 
umbilicus, and in breech cases above it. Transverse presentations can 
even more easily be made out by abdominal palpation. Here the 
long axis of the uterine tumor does not correspond with the long axis 
of the mother's abdomen, but lies obliquely across it. By palpation 
the rounded mass of the head can be easily felt in one of the mother's 
flanks, and the breech in the other, while the foetal heart is heard 
pulsating nearer to the side at which the head is detected. 

i Monats. f. Geburt., 1865, Bd. sxiv. S. 172 ; and 1866, Bd. xxviii. S. 361. " Geburtshlilfliche 
Studien." 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 131 

The reason why the head presents so frequently has been made the 
subject of much discussion. The oldest theory was, that the head lay 
over the os uteri as the result of gravitation, and the influence of 
gravity, although contested by many obstetricians, prominent among 
whom were Dubois and Simpson, has been insisted upon as the chief 

Fig. 65. 



Mode of ascertaining the position of the foetus by palpation. 

cause by others, Dr. Duncan being one of the most strenuous advo- 
cates of this view. The objections urged against the gravitation theory 
were drawn partly from the result of experiments, and partly from 
the frequency with which abnormal presentations occur in premature 
labors, when the action of gravity cannot be supposed to be suspended. 
The experiments made by Dubois went to show, that when the foetus 
was suspended in water, gravitation caused the shoulders, and not the 
head, to fall lowest. He, therefore, advanced the hypothesis that the 
position of the foetus was due to instinctive movements, which it made 
to adapt itself to the most comfortable position in which it could lie. 
It need only be remarked that there is not the slightest evidence of 
the foetus possessing any such power. Simpson proposed a theory 
which was much more plausible. He assumed that the foetal position 
was due to reflex movements produced by physical irritations to 
which the cutaneous surface of the foetus is subjected from changes 
of the mother's position, uterine contractions, and the like. The 
absence of these movements, in the case of the death of the foetus, 
would readily explain the frequency of malpresentations under such 
circumstances. 

The obvious objection to this theory, complete as it seems to be, is 
the absence of any proof that such constant extensive reflex movements 
really do occur in utero. Dr. Duncan has very conclusively disposed 
of the principal objections which have been raised against the influence 
of gravitation, and, when an obvious explanation of so simple a kind 



132 PREGNANCY. 

exists, it seems useless to seek further for another. He has shown 
that Dubois's experiments did not accurately represent the state of the 
foetus in utero, and that during the greater part of the day, when the 
woman is upright, or lying on her back, the foetus lies obliquely to 
the horizon at an angle of about 30°. The child thus lies, in the 
former case, on an inclined plane, formed by the anterior uterine wall 



Diagram illustrating the effect of gravity on the foetus, a, b, is parallel to the axis of the preg- 
nant uterus and pelvic brim, c, d, e, is a perpendicular line, e, the centre of gravity of the 
foetus, d, the centre of flotation. (After Duncan.) 

and the abdominal parietes, in the latter by the posterior uterine 
wall and the vertebral column. Down the inclined plane so formed 
the force of gravity causes the foetus to slide, and it is only when the 
woman lies on her side that the foetus is placed horizontally, and is 
not subjected in the same degree to the action of gravity (Fig. 66). 
The frequency of mal-presentations in premature labors is explained 
by Dr. Duncan partly by the fact that the death of the child (which 
so frequently precedes such cases) alters its centre of gravity, and 
partly by the greater mobility of the child and the greater relative 
amount of liquor amnii (Fig t 67). The effect of gravitation is probably 
greatly assisted by the contractions of the uterus which are going on 
during the greater part of pregnancy. The influence of these was 
pointed out by Dr. Tyler Smith, who distinctly showed that the contrac- 
tions of the uterus preceding delivery exerted a moulding or adapting 
influence on the foetus, and prevented undue alterations of its position. 
Dr. Hicks proved l that these uterine contractions are of constant occur- 
rence from the earliest period of pregnancy, and there can be little 
doubt that they must have an important influence on the body contained 
within the uterus. The whole subject has been recently considered 
by Pinard, 2 who shows that many factors aj*e in action to produce and 
maintain the usual position of the foetus in utero, which may be either 
of an active or a passive character : the former being chiefly the active 

i Obst. Trans., 1872, vol. xiii. p. 216. 
2 Annal. de Gyn., 1878, torn. ix. p. 321. 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 



133 



movements of the fetus and the contractions of the uterus and the 
abdominal muscles ; the latter, the form of the uterus and the foetus, 
the slippery surface of the amnion, pressure of the amniotic fluid, etc. 
When any of these factors are at fault, mal-presentation is apt to 
occur. 

The functions of the foetus are in the main the same, with differ- 
ences depending on the situation in which it is placed, as those of the 
separate being. It breathes, it is nourished, it forms secretions, and 

Fig. 67. 




\<30* 



Illustrating the greater mobility of the foetus and the larger relative amount of liquor amnii in 
early pregnancy, a, b. Axis of pregnant uterus, b, h. A horizontal line. (After Duncan.) 

its nervous system acts. The mode in which some of these functions 
are carried on in intra-uterine life requires separate consideration. 

Nutrition. — During the early part of pregnancy, and before the 
formation of the umbilical vesicle and the allantois, it is certain that 
nutritive material must be supplied to the ovum by endosmosis 
through its external envelope. The precise source, however, from 
which this is obtained is not positively known. By some it is believed 
to be derived from the granulations of the discus proligerus which 
surround it as it escapes from the Graafian follicle, and subsequently 
from the layer of albuminous matter which surrounds the ovum before 
it reaches the uterus ; while others think it probable that it may come 
from a special liquid secreted by the interior of the Fallopian tube as 
the ovum passes along it. As soon as the ovum has reached the 
uterus, there is every reason to believe that the umbilical vesicle is the 
chief source of nourishment to the embryo, through the channel of 
the omphalo-mesenteric vessels, which convey matters absorbed from 
the interior of the vesicle to the intestinal canal of the foetus. At this 
time the exterior of the ovum is covered by numerous fine villosities 
of the primitive chorion, which are imbedded in the mucous mem- 
brane of the uterus, and it is thought that they may absorb materials 
from the maternal system, which may be either directly absorbed by 
the embryo, or which may serve the purpose of replacing the nutritive 
matter which has been removed from the umbilical vesicle by the 
omphalo-mesenteric vessels. This point it is, of course, impossible to 
decide. Joulin, however, thinks that these villi probably have no 



134 PREGNANCY. 

direct influence on the nourishment of the foetus, which is at this time 
solely effected by the umbilical vesicle, but that they absorb fluid from 
the maternal system, which passes through the amnion and forms the 
liquor amnii. As soon as the allantois is developed, vascular com- 
munication between the foetus and the maternal structures is estab- 
lished, and the temporary function of the umbilical vesicle is over ; 
that structure, therefore, rapidly atrophies and disappears, and the 
nutrition of the foetus is now solely carried on by means of the chorion 
villi, lined as they now are by the vascular endochorion, and chiefly 
by those which go to form the substance of the placenta. 

This statement is opposed to the views of many physiologists, who 
believe that a certain amount of nutritive material is conveyed to the 
foetus through the chaonel of the liquor amnii, which is supposed either 
to be absorbed through the cutaueous surface of the foetus, or carried 
to the intestinal canal by deglutition. The reasons for assigning to 
the liquor amnii a nutritive function are, however, so slight that it is 
difficult to believe that it has any appreciable action in this way. They 
are based on some questionable observations, such as those of Weydlich, 
who kept a calf alive for fifteen days by feeding it solely on liquor 
amnii, and the experiments of Burdach, who found the cutaneous 
lymphatics engorged in a foetus removed from the amniotic cavity, 
while those of the intestine were empty. The deglutition of the liquor 
amnii for the purposes of nutrition has been assumed from its occa- 
sional detection in the stomach of the foetus, the presence of which may, 
however, be readily explained by spasmodic efforts at respiration, which 
the foetus undoubtedly often makes before birth, especially when the 
placental circulation is in anyway interfered with, and during which a 
certain quantity of fluid would necessarily be swallowed. The quantity 
of nutritive material, however, in the liquor amnii is so small — not 
more than 6 to 9 parts of albumin in 1000 — that it is impossible to 
conceive that it could have any appreciable influence in nutrition, even 
if its absorption either by the skin or stomach were susceptible of proof. 

That the nutrition of the foetus is effected through the placenta is 
proved by the common observation that whenever the placental circu- 
lation is arrested, as by disease of its structure, the foetus atrophies and 
dies. The precise mode, however, in which nutritive materials are 
absorbed from the maternal blood is still a matter of doubt, and must 
remain so until the mooted points as to the minute anatomy of the 
placenta are settled. 

Respiration. — One of the chief functions of the placenta, besides 
that of nutrition, is the supply of oxygenated blood to the foetus. 
That this is essential to the vitality of the foetus, and that the placenta 
is the site of oxygenation, is shown by the fact that whenever the 
placenta is separated, or the access of foetal blood to it arrested by 
compression of the cord, instinctive attempts at inspiration are made, 
and if aerial respiration cannot be performed, the foetus is expelled 
asphyxiated. Like the other functions of the foetus during intra- 
uterine life, that of respiration has been made the subject of numerous 
more or less ingenious hypotheses. Thus many have believed that 
the foetus absorbed gaseous material from the liquor amnii, which 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 135 

served the purpose of oxygenating its blood, St. Hilaire thinking that 
this was effected by minute openings in its skin, Beclard and others 
through the bronchi, to which they believed the liquor amnii gained 
access. Independently of the entire want of evidence of the absorption 
of gaseous materials by these channels, the theory is disproved by the. 
fact that the liquor amnii contains no air which is capable of respira- 
tion. Serres attributed a similar function to some of the chorion villi, 
which he believed penetrated the utricular glands of the decidua reflexa 
and absorbed gas from the hydroperione, or fluid situated between 
it and the decidua vera, and in this manner he thought the foetal blood 
was oxygenated until the fifth month of intra-uterine life, when the 
placenta was fully formed. 

This hypothesis, however, rests on no accurate foundation, for it is 
certain that the chorion villi do not penetrate the utricular glands in the 
manner assumed ; or, even if they did, the mode in which the oxygen 
thus absorbed by the chorion villi reaches the foetus, which is separated 
from them by the amnion and its contents, would still remain 
unexplained. 

The mode in which the oxygenation of the foetal blood is effected 
before the formation of the placenta remains, therefore, as yet un- 
known. After the development of that organ, however, it is less 
difficult to understand, for the foetal blood is everywhere brought into 
such close contact with the maternal, in the numerous minute ramifica- 
tions of the umbilical vessels, that the interchange of gases can readily 
be effected. The activity of respiration is doubtless much less than in 
extra-uterine life, for the waste of tissue in the foetus is necessarily 
comparatively small, from the fact of its being suspended in a fluid 
medium of its own temperature, and from the absence of the processes 
of digestion and of respiratory movements. The quantity of carbonic 
acid formed would, therefore, be much less than after birth, and there 
would be a correspondingly small call for oxygenation of venous 
circulation. 

Circulation. — The functions of the lungs being in abeyance, it is 
necessary that all the foetal blood should be carried to the placenta 
to receive oxygen and nutritive materials. To understand the mode 
in which this is effected we must bear in mind certain peculiarities in 
the circulatory system which disappear after birth. 

1. The two sides of the foetal heart are not separate as in the adult. 
The right ventricle in the adult sends all the venous blood to the 
lungs through the pulmonary arteries, to be aerated by contact with 
the atmosphere. In the foetus, however, only sufficient blood is passed 
through the pulmonary arteries to insure their being pervious and 
ready to carry blood to the lungs immediately after birth. 

An aperture of communication, the foramen ovale, exists between the 
two auricles, which is arranged so as to permit the blood reaching the 
right auricle to pass freely into the left, but not vice versa. By this 
means a large portion of the blood reaching the heart through the 
veme cavse, instead of passing, as in the adult, into the right ventricle, 
is directed into the left auricle. 

2. Even with this arrangement, however, a larger portion of blood 




136 PREGNANCY. 

would pass into the pulmonary arteries than is required for trans- 
mission to the lungs, and a further provision is made to prevent its 
going to them by means of a foetal vessel, the 
FlG - 68 - ductus arteriosus (Fig. 68), which arises from the 

point of bifurcation of the pulmonary arteries, 
and opens into the arch of the aorta. In con- 
sequence of this arrangement only a very small 
portion of the blood reaches the lungs at all. 

3. The foetal hypogastric arteries are continued 

into large arterial trunks, which, passing into the 

cord, form the umbilical arteries, and carry the 

Diagram of foetal heart, impure foetal blood into the placenta. 

i. Aorta. 2. Pulmonary 4. The purified blood is collected into the 

artery. 3, 3. Pulmonary s i n gi e umbilical vein, through which it is carried 

Dr£iiic.ti6S. 4 Ductus £IT- ^ ■ O 

teriosus. (After dalton.) to the under surface of the liver, from which point 
it is conducted, by means of another special foetal 
vessel, the ductus venosus, into the ascending vena cava and the right 
auricle. 

In order to understand the course of the foetal blood it may be 
most conveniently traced from the point where it reaches the under 
surface of the liver through the umbilical vein. Part of it is dis- 
tributed to the liver itself, but the greater quantity is carried directly into 
the inferior vena cava, through the ductus venosus. The inferior vena- 
cava also receives the blood from the foetal veins of the lower extremi- 
ties, and that portion of the blood of the umbilical vein which has 
passed through the liver. This mixed blood is carried up to the right 
auricle, from which by far the greater part of it is immediately directed 
into the left auricle, through the foramen ovale. From thence it 
passes into the left ventricle, which sends the greater part of it into the 
head and upper extremities through the aorta, a comparatively small 
quantity being transmitted to the inferior extremities. The blood 
which is thus sent to the upper part of the body is collected into the 
vena cava superior, by which it is thrown into the right auricle. 
Here the mass of it is probably directed into the right ventricle, which 
expels it into the pulmonary arteries, and from thence, through the 
ductus arteriosus, into the descending aorta. By this arrangement it 
will be seen that the descending aorta conveys to the lower part of the 
body the comparatively impure blood which has already circulated 
through the head, neck, and upper extremities. From the descending 
aorta a small quantity of blood is conveyed to the lower extremities, 
the greater part of it being carried for purification to the placenta 
through the umbilical arteries. 

As soon as the child is born it generally cries loudly and inflates 
its lungs, and, in consequence, the pulmonary arteries are dilated and 
the greater portion of the blood of the right ventricle is at once sent 
to the lungs, from whence, after being arterialized, it is returned to 
the left auricle, through the pulmonary veins. The left auricle, there- 
fore, receives more blood than before, the right less, and, the placental 
circulation being arrested, no more passes through the umbilical vein. 
In consequence of this, the pressure of the blood in the two auricles is 



ANATOMY AND PHYSIOLOGY OF THE FCETUS. 137 

equalized, the mass of the blood in the right auricle no longer passes 
into the left (the valve of the foramen ovale being closed by the equal 
pressure on both sides), but directly into the right ventricle and from 
thence into the pulmonary arteries, and the ductus arteriosus soon 
collapses and becomes impervious. The mass of blood in the descending 
aorta no longer finds its way into the hypogastric arteries, but passes 
into the lower extremities, and the adult circulation is established. 

The changes which take place in the temporary vascular arrange- 
ments in the foetus, prior to their complete disappearance, are of some 
practical interest. The ductus arteriosus, as has been said, collapses, 
chiefly because the mass of blood is drawn to the lungs, and partly, 
perhaps, by its own inherent contractility. Its walls are found to be 
thickened, and its canal closes, first in the centre, and subsequently at 
its extremities, its aortic end remaining longer pervious on account of 
the greater pressure of blood from the left side of the heart (Fig. 69). 
Practical closure occurs within a few days after birth, although 
Flourens states that it is not completely obliterated until eighteen months 
or two years have elapsed. 1 According to Schroeder its walls unite 
without the formation of any thrombus. The foramen ovale is soon 
closed by its valve, which contracts adhesion with the edges of the 
aperture, so as effectually to occlude it. Sometimes, however, a small 
canal of communication between the two 
auricles may remain pervious for many FlG - 69 - 

months, or even a year or more, without, 
however, any admixture of blood occurring. 
A permanently patulous condition of this 
aperture, however, sometimes exists, giving 
rise to the disease known as cyanosis. 

The umbilical arteries and veins and the 
ductus venosus soon also become imper- 
meable, in consequence of concentric hyper- 
trophy of their tissue and collapse of their 
walls. The closure of the former is aided 
by the formation of coagula in the interior. Diagram of heart of infant. 




According to Robin, a longer time than is Aorta. 2. Pulmonary artery. 

usually supposed elapses before they become £S~ *£*£ &S2Z 
completely closed, the vein remaining per- ( After daltox.) 
vious until the twentieth or thirtieth day 

after delivery, the arteries for a month or six weeks. He has also 
described 2 a* remarkable contraction of the umbilical vessels within 
their sheaths, at the point where they leave the abdominal walls, 
which takes place within three or four days after birth, and seems to 
prevent hemorrhage taking place when the cord is detached. 

Function of the Liver. — The liver, from its proportionately large 
size, apparently plays an important part in the foetal economy. It is 
not until about the* fifth month of utero-gestation that it assumes its 
characteristic structure, and forms bile, previous to that time its texture 
being soft and undeveloped. According to Claude Bernard, after this 

1 Acad, des Sciences, 1854. 2 Ibid., 1860. 



138 PREGNANCY. 

period one of its most important offices is the formation of sugar, which 
is found in much larger amount in the foetus than after birth. Sugar 
is, however, found in the foetal structures long before the development 
of the liver, especially in the mucous and cutaneous tissues, and it 
seems probable that these, as well as the placenta itself, then fulfil the 
glycogenic function, afterward chiefly performed by the liver. The 
bile is secreted after the fifth month of pregnancy, and passes into the 
intestinal canal, and is subsequently collected in the gall-bladder. By 
some physiologists it has been supposed that the liver, during intra- 
uterine life, was the chief seat of depuration of the carbonic acid 
contained in the venous blood of the foetus. It is, however, more 
generally believed that this is accomplished solely in the placenta. 
The bile, mixed with the mucous secretion of the intestinal tract, forms 
the meconium which is contained in the intestines of the foetus, and 
which collects in them during the whole period of intra-uterine life. 
It is a thick, tenacious, greenish substance, which is voided soon after 
birth in considerable quantity. 

The Urine. — Urine is certainly formed during intra-uterine life, as 
is proved by the fact familiar to all accoucheurs, that the bladder is con- 
stantly emptied instantly after birth. It has generally been supposed 
that the foetus voids its urine into the cavity of the amnion, and the 
existence of traces of urea in the liquor amnii, as well as some cases of 
imperforate urethra, in which the bladder was found to be enormously 
distended, and some cases of congenital hydro-nephrosis associated with 
impervious ureters, have been supposed to corroborate this assumption. 
The question has been very fully studied by Joulin, who has collected 
together a large number of instances in which there was imperforate 
urethra without any undue distention of the bladder. He holds also, 
that the amount of urea found in the liquor amnii is far too minute to 
justify the conclusion that the urine of the foetus was habitually passed 
into it, although a small quantity may, he thinks, escape into it from 
time to time ; and he therefore believes that the urine of the foetus is 
only secreted regularly and abundantly after birth, and that during 
intra-uterine life its retention is not likely to give rise to any functional 
disturbance. 

Function of the Nervous System. — There is no doubt that the 
nervous system acts to a considerable extent during intra-uterine life, 
and some authors have even supposed that the foetus was endowed with 
the power of making instinctive or voluntary movements for the pur- 
pose of adapting itself to the form of the uterine cavity. Most prob- 
ably, however, the movements the foetus performs are purely reflex. 
That it responds to a stimulus applied to the cutaneous nerves is proved 
by the experiments of Tyler Smith, who laid bare the amnion in preg- 
nant rabbits, and found that the foetus moved its limbs when these 
were irritated through it. Pressure on the mother's abdomen, cold 
applications, and similar stimuli will also produce energetic foetal 
movements. The gray matter of the brain in the newborn child is, 
however, quite rudimentary in its structure, and there is no evidence 
of intelligent action of the nervous system until some time after birth, 
and a fortiori during- pregnancy. 



PREGNANCY. 139 

CHAPTEE III. 

PREGNANCY. 

Changes in the Uterus. — As soon as conception has taken place a 
series of remarkable changes commence in the uterus, which progress 
until the termination of pregnancy, and are well worthy of careful 
study. They produce those marvellous modifications which effect the 
transformation of the small undeveloped uterus of the non-pregnant 
state into the large and fully developed uterus of pregnancy, and have 
no parallel in the whole animal economy. 

A knowledge of them is essential for the proper comprehension of 
the phenomena of labor, and for the diagnosis of pregnancy which the 
practitioner is so frequently called upon to make. Excluding the 
varieties of abnormal pregnancy, which will be noticed in another 
place, we shall here limit ourselves to the consideration of the modifi- 
cations of the maternal organism which result from simple and natural 
gestation. 

The unimpregnated uterus measures two and a half inches in length 
and weighs about one ounce, while at the full term of pregnancy it 
has so immensely grown as to weigh twenty-four ounces and measure 
twelve inches. The growth commences as soon as the ovum reaches 
the uterus, and continues uninterruptedly until delivery. In the early 
months the uterus is contained entirely in the cavity of the pelvis, and 
the increase of size is only apparent on vaginal examination, and that 
with difficulty. Before the third month the enlargement is chiefly in 
the lateral direction, so that the whole body of the uterus assumes more 
of a spherical shape than in the non-pregnant state. This gives to the 
examining finger the impression of a spheroidal body placed over the 
conoidal cervix, which at this time is little altered in shape. If now 
a bi-manual examination is made, the lower uterine segment in front 
will be felt to be elastic and semi-fluctuating (Hegar's sign). After the 
ascent of the uterus into the abdominal cavity these changes cannot be 
so readily made out. If an opportunity of examining the gravid uterus 
post-mortem should occur at this time, it will be found to have the 
form of a sphere flattened somewhat posteriorly, and bulging anteriorly. 

After the ascent of the organ into the abdomen it develops more in 
the vertical direction, so that at term it has the form of an ovoid, with 
its large extremity above and its narrow end at the cervix uteri, and 
its longitudinal axis corresponds to the long diameter of the mother's 
abdomen, provided the presentation be either of the head or breech. 
The anterior surface is now even more distinctly projecting than before 
— a fact which is explained by the proximity of the posterior surface 
to the rigid spinal column behind, while the anterior is in relation with 
the lax abdominal parietes, which yield readily to pressure, and so 
allow of the more marked prominence of the anterior uterine wall. 



140 



PREGNANCY 



Before the gravid uterus has riseu out of the pelvis no appreciable 
increase in the size of the abdomen is perceptible. On the contrary, 
it is an old observation that at this early stage of pregnancy the abdo- 
men is flatter than usual, on account of the partial descent of the uterus 
in the pelvic cavity as a result of its increased weight. As the growth 
of the organ advances, it soon becomes too large to be contained any 
longer within the pelvis, and about the middle of the third or the 
beginning of the fourth month the fundus rises above the pelvic brim — 
not suddenly, as is often erroneously thought, but slowly and gradually 
— when it may be felt as a smooth rounded swelling. 



Fig. 70. 



Fig. 71. 




Relations of the pregnant uterus at sixth month to 
the surrounding parts. (After Martin.) 



Size of uterus at various periods of 
pregnancy. 

It is about this time that the 
movements of the foetus first be- 
come appreciable to the mother, 
when ' ' quickening " is said to 
have taken place. Toward the 
end of the fourth month the 
uterus reaches to about three 
fingers' breadth above the sym- 
physis pubis. About the fifth month it occupies the hypogastric region, 
to which it imparts a marked projection, and the alteration in the 
figure is now distinctly perceptible to visual examination. About the 
sixth month it is on a level with, or a little above, the umbilicus 
(Fig. 70). About the seventh month it is about two inches above the 
umbilicus, which is now projecting and prominent, instead of depressed, 
as in the non-pregnant state. During the eighth and ninth months it 
continues to increase until the summit of the fundus is immediately 
below the ensiform cartilage (Fig. 71). A more accurate estimate of 



PREGNANCY 



141 



the size of the uterine tumor at various periods of pregnancy can be 
obtained by measuring the distance between the fundus uteri and the 
upper margin of the symphysis pubis either with callipers or a measur- 
ing tape. The accompanying table gives the dimensions from the 
measurements of Spiegelberg 1 and Sutugin : 2 

Size of Uterus at Various Stages of Pregnancy. 







Height of fundus uteri 


Height of fundus uteri 




Week of pregnancy. 


above pubes, measured 


above pubes 


measured 






by tape (Spiegelberg). 


by callipers 


(Sutugin). 


22d ) 




f 


6 inches 


24th )- 




8.5 inches < 


6.6 


" 


26th) 




I 


7.3 


ii 


28th . 


. . 


10.5 


7.8 


•« 


30th . 




11.0 " 


8.3 


•* 


32d . 




11.5 " 


8.7 


" 


34th . 




12.0 " 


9.0 


" 


36th . 




12.5 


9.3 


n 


38th . 




13.0 


9.6 


it 


40th . 




13.2 " 


10.0 





The former employed a tape measure, the latter callipers, and his 
results are, therefore, more accurate. 

A knowledge of the size of the uterine tumor at various periods of 
pregnancy, as thus indicated, is of considerable practical importance, 
as forming the only guide by which we can estimate the probable 
period of delivery in certain cases in which the usual data for calcu- 
lation are absent, as, for example, when the patient has conceived 
during lactation. 

For about a week or more before labor the uterus generally sinks 
somewhat into the pelvic cavity, in consequence of the relaxation of 
the soft parts which precedes delivery, and the patient now feels her- 
self smaller and lighter than before. This change is familiar to all 
childbearing women, to whom it is known as " the lightening before 
labor." 

"While the uterus remains in the pelvis its longitudinal axis varies 
in direction, much in the same way as that of the non-pregnant uterus, 
sometimes being more or less vertical, at others in a state of ante- 
version or partial retroversion. These variations are probably de- 
pendent on the distention or emptiness of the bladder, as its state 
must necessarily affect the position of the movable body poised behind 
it. After the uterus has risen into the abdomen, its tendency is to 
project forward against the abdominal Avail, which forms its chief 
support in front. In the erect position the long axis of the uterine 
tumor corresponds with the axis of the pelvic brim, forming an angle 
of about 30° with the horizon. In the semi-recumbent position, on 
the other hand, as Duncan 1 has pointed out, its direction becomes 
much more nearly vertical. In women who have borne man}' chil- 
dren, the abdominal parietes no longer afford an efficient support, and 
the uterus is displaced anteriorly, the fundus in extreme cases even 
hanging downward. 



i Lehrbuch der Geb., Bd. ii. S 115. 

2 Obst. Journ. of Great Britain and Ireland, 1875, vol. in. 



Researches in Obstetrics p 10. 



142 PREGNANCY. 

In addition to this anterior obliquity, on account of the projection 
of the spinal column, the uterus is very generally also displaced lat- 
erally, and sometimes to a very marked degree, so that it may be felt 
entirely in one flank, instead of in the centre of the abdomen. In a 
large proportion of cases this lateral deviation is to the right side, and 
many hypotheses have been brought forward to explain this fact, none 
of them being satisfactory. It is also very frequently rotated in its 
longitudinal axis, so that one ovary, usually the left, lies forward 
toward the middle line, the other backward. Thus, it has been sup- 
posed to depend on the greater frequency with which women lie on 
their right side during sleep, on the greater use of the right leg during 
walking, on the supposed comparative shortness of the right round 
ligament, which drags the tumor to that side, on irregular contractions 
of the muscular fibres in the uterus itself, 1 or on the frequent distention 
of the rectum on the left side, which prevents the uterus being displaced 
in that direction. Of these the last is the cause which seems most con- 
stantly in operation, and most likely to produce the effect. 

The cervix must obviously adapt itself to the situation of the body 
of the uterus. We find, therefore, that in the early months, when the 
uterus lies low in the pelvis, it is more readily within reach. After 
the ascent of the uterus, it is drawn up, and frequently so much as to 
be reached with difficulty. When the uterus is much anteverted, as is 
so often the case, the os is displaced backward, so that it cannot be felt 
at all by the examining finger. 

Toward the end of pregnancy the greater part of the anterior sur- 
face of the uterus is in contact with the abdominal wall, its lower 
portion resting on the posterior surface of the symphysis pubis. The 
posterior surface rests on the spinal column, while the small intestines 
are pushed to either side, the large intestines surrounding the uterus 
like an arch. 

Changes in the Uterine Parietes. — The great distention of the 
uterus during pregnancy was formerly supposed to be mainly due to 
the mechanical pressure of the enlarging ovum within it. If this 
were so, then the uterine walls would be necessarily much thinner 
than in the non-pregnant state. This is well known not to be the 
case, and the immense increase in the size of the uterine cavity is to 
be explained by the hypertrophy of its walls. At the full period of 
pregnancy the thickness of the uterine parietes is generally about the 
same as that of the non-pregnant uterus, rather more at the placental 
site, and less in the neighborhood of the cervix. Their thickness, 
however, varies in different places, and in some women they are so 
thin as to admit of the foetal limbs being very readily made out by 
palpation. Their density is, however, always much diminished, and, 
instead of being hard and inelastic, they become soft and yielding to 
pressure. This change coincides with the commencement of pregnancy, 
of which it forms, as recognizable in the cervix, one of the earliest 
diagnostic marks. At a more advanced period it is of value as admit- 

i Deflection and Rotation of the Pregnant and Puerperal Uterus. R. Milue Murray, Edin. Med. 
Journ., February, 1897. 



PREGNANCY, 



143 



ting a certain amount of yielding of the uterine walls to movements 
of the foetus, thus lessening the chance of their being injured. Baudl 
has pointed out that during the latter months of pregnancy the lower 
segment of the uterus, to a distance of from four to six inches above 
the inner os, is thinner and less vascular than the tissues of the body 
of the uterus above. This thinner portion is separated from that above 
it by a ridge, often easily made out when the hand has to be inserted 
into the uterus after delivery, known as " Bandl's ring. 7 ' x 

Changes in the Cervix during" Pregnancy. — Very erroneous 
views have long been taught, in most of our standard works on mid- 
wifery, as to the changes which occur in the cervix uteri during preg- 
nancy. It is generally stated that, as pregnancy advances, the cervical 
cavity is greatly diminished in length, in consequence of its being 
gradually drawn up so as to form part of the general cavity of the 
uterus, so that in the latter months it no longer exists. In almost all 



Fig. 72. 



Fig. 73. 





Fig. 74. 



Fig. 75. 





Supposed shortening of the cervix at the third, sixth, eighth, and ninth months of pregnancy, 
as figured in obstetric works. 



midwifery works accurate diagrams are given of this progressive short- 
ening of the cervix (Figs. 72 to 75). The cervix is generally described 
as having lost one-half of its length at the sixth month, two-thirds at 
the seventh, and to be entirely obliterated in the eighth and ninth. 
The correctness of these views was first called in question in recent 
times by Stoltz, in 1826, but Dr. Duncan, 2 in an elaborate historical 
paper on the subject, has shown that Stoltz was anticipated by Weit- 
brech in 1750, and to a less degree by Roederer and other writers. 
Their opinion is now pretty generally admitted to be correct, and is 
upheld by Cazeaux, Arthur Farre, Duncan, and most modern obste- 
tricians. Indeed, various post-mortem examinations in advanced preg- 

1 Ueber das Verhalten des Uterus und Cervix in der Schwangerschaft und wiihrend der Geburt. 
1876. - Researches in Obstetrics. 



144 



PREGNANCY. 



nancy have shown that the cavity of the cervix remains in reality of 
its normal length of one inch, and it can often be measured during 
life by the examining finger, on account of its patulous state (Fig. 76). 
During the fortnight immediately preceding delivery, however, a real 
shortening or obliteration of the cervical cavity takes place, com- 
mencing above, until the cervical canal is merged into the uterine 
cavity ; but this, as Duncan has pointed out, seems to be due to the 
incipient uterine contractions which prepare the cervix for labor. 

There is, no doubt, an apparent shortening of the cervix always to 
be detected during preguancy, but this is a fallacious and deceptive 
feeling, due to the softness of the tissue of the cervix, which is exceed- 
ingly charateristic of pregnancy, and which to an experienced finger 
affords one of its best diagnostic marks, and to some extent also the 
alteration in the direction of the cervical canal which accompanies preg- 
nancy. 

Fig. 76. 




Cervix from a woman dying in the eighth month of pregnancy. (After Duncan.) 



In the non-pregnant state the tissue of the cervix is hard, firm, and 
inelastic. When conception occurs, softening begins at the external 
os, and proceeds gradually and slowly upward until it involves the 
whole of the cervix. It results from serous infiltration of the tissues, 
associated with passive dilatation of the vessels. By the end of the 
fourth month both lips of the os are thick, softened, and velvety to 
the touch, giving a sensation likened by Cazeaux to that produced by 
pressing on a table through a thick, soft cover. By the sixth month 
at least one-half of the cervix is thus altered, and by the eighth the 
whole of it, and so much so that at this time those unaccustomed to 



PREGNANCY. 145 

vaginal examination experience some difficulty in distinguishing it 
from the vaginal walls. It is this softening, then, which gives rise to 
the apparent shortening of the cervix so generally described, and it is 
an invariable concomitant of pregnancy, except in some rare cases in 
which there has been antecedent morbid induration and hypertrophic 
elongation of the cervix. If, therefore, on examining a woman sup- 
posed to be advanced in pregnancy, we find the cervix to be hard and 
projecting into the vaginal canal, we may safely conclude that preg- 
nancy does not exist. The existence of softening, however, it must be 
remembered, will not itself justify an opposite conclusion, as it may 
be produced, to a very considerable extent, by various pathological 
conditions of the uterus. 

At the same time that the tissue of the cervix is softened, its cavity 
is widened, and the external os becomes patulous. This change varies 
considerably in primiparse and multiparas. In the former the external 
os often remains closed until the end of pregnancy ; but even in them 
it generally becomes more or less patulous after the seventh month, 
and admits the tip of the examining finger. In women who have 
borne children this change is much more marked. The lips of the 
external os are in them generally fissured and irregular, from slight 
lacerations of its tissue in former labors. It is also sufficiently opeu 
to admit the tip of the finger, so that in the latter months of preg- 
nancy it is often quite possible to touch the membranes, and through 
them to feel the presenting part of the child. 

The remarkable increase in size of the uterus during pregnancy is, 
as we have seen, chiefly to be explained by the growth of its struc- 
tures, all of which are modified during gestation. The peritoneal 
covering is considerably increased, so as still to form a complete cover- 
ing to the uterus when at its largest size. William Hunter supposed 
that its extension was effected rather by the unfolding of the layers of 
the broad ligament than by growth. That the layers of the broad 
ligament do unfold during gestation, especially in the early months, is 
probable ; but this is not sufficient to account for the complete invest- 
ment of the uterus, and it is certain that the peritoneum grows pari 
'passu with the enlargement of the uterus. In addition, there is a 
new formation of fibrous tissue between the peritoneal and the mus- 
cular coats, which affords strength, and diminishes the risk of lacera- 
tion during labor. 

The hypertrophy of the muscular tissue of the uterus is, however, 
the most remarkable of the changes produced by pregnancy. Not 
only do the previously existing rudimentary fibre-cells become enor- 
mously increased in size — so as to measure, according to Kolliker, 
from seven to eleven times their former length, and from two to five 
times their former breadth — but new unstriped fibres are largely 
developed, especially in the inner layers. These new cells are chiefly 
found in the first months of pregnancy, and their growth seems to be 
completed by the sixth month. The connective tissue between the 
muscular layers is also largely increased in amount. The weight of 
the muscular tissue of the gravid uterus is, therefore, much increased, 
and it has been estimated by Heschl that it weighs at term from 1 to 
10 



146 PKEGNANCY. 

1.5 lb., that is, about sixteen times more than in the unimpregDatecl 
State. This great development of the muscular tissue admits of its 
dissection in a way which is quite impossible in the unimpregnated 
state, and the researches of Helie (p. 6b) enable us to understand much 
better than before how the muscles forming the walls of the gravid 
uterus act during the expulsion of the child. 

The changes in the mucous coat of the uterus which result in the 
formation of the decidua have already been discussed at length 
elsewhere (p. 108). 

The circulatory apparatus of the uterus during pregnancy has been 
described when the anatomy of the placenta was under consideration 
(p. 112). 

The lymphatics are much increased in size ; and recent theories on 
the production of certain puerperal diseases attribute to them a more 
important action than has been commonly assigned to them. 

The question of the growth of the nerves has been hotly discussed. 
Robert Lee took the foremost place among those who maintained that 
the nerves of the uterus share the general growth of its other con- 
stituent parts. Dr. Snow Beck, however, believed that they remain 
of the same size as in the unimpregnated state, and this view is sup- 
ported by Hirsch field, Robin, and other recent writers. Robin thought 
that there is an apparent increase in the size of the nerve-tubes, 
which, however, is really due to increase in the neurilemma. Kilian 
describes the nerves as increasing in length but not in thickness, 
while Schroeder states that they participate equally with the lym- 
phatics in the enlargement the latter undergo. Whichever of these 
views may ultimately be found to be correct, it is certain that analogy 
would lead us to expect an increase of nervous as well as of vascular 
supply. 

General Modifications in the Body produced by Pregnancy. — 
It is not in the uterus alone that pregnancy is found to produce modi- 
fications of importance. There are few of the more important functions 
of the body which are not, to a greater or less extent, affected ; to 
some of these it is necessary briefly to direct attention, inasmuch as, 
when carried to excess, they produce those disorders which often com- 
plicate gestation, and which prove so distressing and even dangerous 
to the patients. Such of them as are apparent and may aid us in 
diagnosis are discussed in the chapter which treats of the signs and 
symptoms of pregnancy ; in this place it is only necessary to refer to 
those which do not properly fall into that category. 

Amongst those which are most constant and important are the 
alterations in the composition of the blood. The opinion of the pro- 
fession on this subject has, of late years, undergone a remarkable 
change. Formerly it was universally believed that pregnancy was 
associated with a condition analogous to plethora, and that this 
explained many characteristic phenomena of common occurrence, 
such as headache, palpitation, singing in the ears, shortness of 
breath, and the like. As a consequence it was the habitual custom, 
not yet by any means entirely abandoned, to treat pregnant women on 
an antiphlogistic system; to place them on low diet, to administer 






PREGNANCY. 147 

lowering remedies, and very often to practise venesection, sometimes 
to a surprising extent. Thus it was by no means rare for women to 
be bled six or eight times during the latter months, even when no 
definite symptoms of disease existed ; and many of the older authors 
record cases where depletion was practised every fortnight as a matter 
of routine, and, when the symptoms were well marked, even from 
fifty to ninety times in the course of a single pregnancy. 

Composition of the Blood in Pregnancy. — Numerous careful 
analyses have conclusively proved that the composition of the blood 
during pregnancy is very generally — perhaps it would not be too 
much to say always — profoundly altered. To meet the necessities of 
the largely increased vascular arrangements of the uterus, the total 
amount of blood in the system is increased. 1 It is found to be more 
watery, its serum is deficient in albumin, and the amount of colored 
globules is materially diminished, averaging, according to the analysis 
of Becquerel and Rodier, 111.8 against 127.2 in the non-gravid state. 
At the same time the amount of fibrin and of extractive matter is 
considerably increased. The latter observation is of peculiar impor- 
tance, and it goes far to explain the frequency of certain thrombotic 
affections observed in connection with pregnancy and delivery ; this 
hyperinosis of the blood is also considerably increased after labor by 
the quantity of effete material thrown into the mother's system at that 
time, to be got rid of by her emunctories. The truth is, that the 
blood of the pregnant woman is generally in a state much more nearly 
approaching the condition of anaemia than of plethora, and it is certain 
that most of the phenomena attributed to plethora may be explained 
equally well and better on this view. These changes are much more 
strongly marked at the latter end of pregnancy than at its commence- 
ment, and it is interesting to observe that it is then that the concomi- 
tant phenomena alluded to are most frequently met with. Cazeaux, 
to whom we are chiefly indebted for insisting on the practical bearing 
of these views, contends that the pregnant state is essentially analogous 
to chlorosis, and that it should be so treated. More recently the 
accurate observations of Willcocks 2 have shown that the blood of 
pregnancy differs from that of chlorosis in the fact that while in both 
the amount of haemoglobin is lessened, in pregnancy the individual 
blood-cells are not impoverished as they are in chlorosis, but simply 
lessened in comparative number, owing to an increase in the water of 
the plasma, due to the progressive enlargement of the vascular area 
during gestation. Objection has not unnaturally been taken to 
Cazeaux's theory, as implying that a healthy and normal function is 
associated with a morbid state, and it has been suggested that this de- 
teriorated state of the blood may be a wise provision of Nature instituted 
for a purpose we are not as yet able to understand. It may certainly 
be admitted that pregnancy, in a perfectly healthy state of the system, 
should not be associated with phenomena in themselves in any degree 
morbid. It must not be forgotten, however, that our patients are 

» Arch. f. Gvnak., 1872, Bd. iv. S. 112. 

2 "Comparative Observations on the Blood in Chlorosis and Pregnancy," by Fred. Willcocks, 
M.D., The Lancet, December 3, 1881. 



148 PREGNANCY. 

seldom — we might safely say never — in a state that is physiologically 
healthy. The influence of civilization, climate, occupation, diet, and 
a thousand other disturbing causes that, to a greater or less degree, 
are always to be met with, must not be left out of consideration. 
Making every allowance, therefore, for the undoubted fact that preg- 
nancy ought to be a perfectly healthy condition, it must be conceded, 
I think, that in the vast majority of cases coming under our notice it 
is not entirely so ; and the deductions drawn by Cazeaux, from the 
numerous analyses of the blood of pregnant women, seem to point 
strongly to the conclusion that the general blood-state is tending to 
poverty and anaemia, and that a depressing and antiphlogistic treatment 
is distinctly contra-indicated. 

Modifications in certain Viscera. — Closely connected with the 
altered condition of the blood is the physiological hypertrophy of the 
heart, which is now well known to occur during pregnancy. This 
was first pointed out by Larcher in 1828, and it has been since verified 
by numerous observers. It seems to be constant and considerable, 
and to be a purely physiological alteration intended to meet the 
increased exigencies of the circulation which the complex vascular 
arrangements of the gravid uterus produce. The hypertrophy is 
limited to the left ventricle; the right ventricle, as Avell as both 
auricles, being unaffected. Blot estimates that the whole weight of 
the heart increases one-fifth during gestation. The researches of 
Lohlein 1 render it probable that the hypertrophy is less than those 
authors have supposed. According to Duroziez 2 the heart remains 
enlarged during lactation, but diminishes in size immediately after 
delivery in women who do not suckle, while in women who have 
borne many children it remains permanently somewhat larger than in 
nulliparae. Similar increase in the size of other organs has been pointed 
out by various writers, as, for example, in the lymphatics, the spleen, 
and the liver. Tarnier states that in women who have died after 
delivery, the organs always show signs of fatty degeneration. Accord- 
ing to Gassner, the whole body increases in weight during the latter 
months of pregnancy, and this increase is somewhat beyond that which 
can be explained by the size of the womb and its contents. 

Formation of Osteophytes. — Irregular bony deposits between the 
skull and the dura mater, in some cases so largely developed as to line 
the whole cranium, have been so frequently detected in women who 
have died during parturition that they are believed by some to be a 
normal production connected with pregnancy. Ducrest found these 
osteophytes in more than one-third of the cases in which he performed 
post-mortem examinations during the puerperal period. Rokitansky, 
who corroborated the observation, believed this peculiar deposit of 
bony matter to be a physiological, and not a pathological, condition 
connected with pregnancy ; but whether it be so, or how it is produced, 
has not yet been satisfactorily determined. 

Changes in the Nervous System. — More or less marked changes 

1 Zeitschrift far Geburtshulfe und Gynak., 1876, Bd. i. S. 482, " Ueber das Verhalten des Herzens 
bei Schwangeren u. Wochnerinnen." 
a Gaz. des Hopit, 1868. 



PREGNANCY. 149 

connected with the nervous system are generally observed in pregnancy, 
and sometimes to a very great extent. When carried to excess they 
produce some of the most troublesome disorders which complicate 
gestation, such as alterations in the intellectual functions, changes in 
the disposition and character, morbid cravings, dizziness, neuralgia, 
syncope, and many others. They are purely functional in their char- 
acter, and disappear rapidly after delivery, and may be best described 
in connection with the disorders of pregnancy. 

Changes in the Respiratory Organs. — Respiration is often in- 
terfered with, from the mechanical results of the pressure of the 
enlarged uterus. The longitudinal dimensions of the thorax are 
lessened by the upward displacement of the diaphragm, and this 
necessarily leads to some embarrassment of the respiration, which is, 
however, compensated, to a great extent, by an increase in breadth of 
the base of the thoracic cavity. 

Changes in the Liver. — The liver has been observed to show 
certain changes in pregnancy. Numerous small yellow spots are seen 
scattered through its substance, varying in size from a pin's head to a 
millet-seed, and these are produced by fatty deposits in the hepatic 
cells, which De Sinety believes to be associated mainly with lactation, 
and to disappear when that is concluded. 

Changes in the Urine. — Certain changes, which are of very con- 
stant occurrence, in the urine of pregnant women have attracted much 
attention, and have been considered by many writers to be pathogno- 
monic. They consist in the presence of a peculiar deposit, formed 
when the urine has been allowed to stand for some time, which has 
received the name of kiestein. Its presence was known to the ancients, 
and it was particularly mentioned by Savonarola in the fifteenth cen- 
tury, but it has more especially been studied within the last thirty 
years by Eguisier, Goldiug Bird, and others. If the urine of a preg- 
nant woman be allowed to stand in a cylindrical vessel, exposed to 
light and air, but protected from dust, in a period varying from two 
to seven days, a peculiar flocculent sediment, like fine cotton-wool, 
makes its appearance in the centre of the fluid, and soon afterward 
rises to the surface and forms a pellicle, which has been compared to 
the fat of cold mutton-broth. In the course of a few days the scum 
breaks up and falls to the bottom of the vessel. On microscopic 
examination it is found to be composed of fat particles, with crystals 
of ammoniaco-magnesium phosphates and phosphate of lime, and a 
large quantity of vibriones. These appearances are generally to be 
detected after the second month of pregnancy, and up to the seventh 
or eighth month, after which they are rarely produced. Regnauld 
explains their absence during the latter months of gestation by the 
presence in the urine, at that time, of free lactic acid, which increases 
its acidity, and prevents the decomposition of the urea into carbonate 
of ammonia. He believes that kiestein is produced by the action of 
free carbonate of ammonia on the phosphate of lime contained in the 
urine, and that this reaction is prevented by the excess of acid. 

Golding Bird believed kiestein to be analogous to casein, to the 
presence of which he referred it, and lie states that he has found it in 



150 PREGNANCY. 

twenty-seven oat of thirty cases. Braxton Hicks so far corroborates 
this view, and states that the deposit of kiestein can be much more 
abundantly produced if one or two teaspoonfuls of rennet be added to 
the urine, since that substance has the property of coagulating casein. 
Much less importance, however, is now attached to the presence of 
kiestein than formerly, since a precisely similar substance is sometimes 
found in the urine of the non-pregnant, especially in anaemic women, 
and even in the urine of men. Parkes states that it is not of uniform 
composition, that it is produced by the decomposition of urea, and 
consists of the free phosphates, bladder mucus, infusoria, and vaginal 
discharges. Neugebauer and Yogel give a similar account of it, and 
hold that it is of no diagnostic value. That it is of interest as indi- 
cating the changes going on in connection with pregnancy, is certain ; 
but inasmuch as it is not of invariable occurrence, and may even exist 
quite independently of gestation, it is obviously quite undeserving of 
the extreme importance that has been attached to it. 

Toward the end of pregnancy sugar may sometimes be detected in 
the urine, and after delivery and during lactation it exists in consider- 
able abundance ; thus, out of thirty-five cases tested in the Simpson 
Memorial Hospital in Edinburgh during the puerperium, it was found 
in all, the amount varying from 1 to 8 per cent. 1 Kaltenbach has 
shown that this temporary glycosuria is due to the presence of milk- 
sugar in the urine, and that it ceases with the disappearance of milk 
from the breasts. 2 This physiological glycosuria must be carefully 
distinguished from true diabetes, which is a grave complication of 
pregnancy. 

Albumin is often present during the latter stages of pregnancy, and 
it may be transitory and of comparatively little moment, although its 
presence must always be a cause of some anxiety. Leyden believes 
that it is most often met with in the second half of a first pregnancy, 
and it may become chronic, leading to granular atrophy of the kid- 
neys. 3 Its frequency has been variously estimated as from 2 to 6 per 
cent, and even as much as 10 per cent., and it is most frequently found 
in primi parse. In some cases it seems to be the result of catarrhal 
conditions of the bladder, in others it is probably caused by undue 
arterial tension consequent on pregnancy. 

i Edin. Med. Journ,, vol. 1881-82. p. 116. 

2 Zeit. f. Geburt. u. Gyn., 1879, Bd. iv. p. 161, "Die Lactosurie der Wochnerinnen." 

3 Deutsche med. Wochenschr., 1886, No. 9. 



SIGNS AND SYMPTOMS OF PREGNANCY. 151 



CHAPTEE IV. 

SIGNS AND SYMPTOMS OF PKEGNANCY. 

Ix attempting to ascertain the presence or absence of pregnancy, the 
practitioner has before him a problem which is often beset with great 
difficulties, and on the proper solution of which the moral character 
of his patient, as Avell as his own professional reputation, may depend. 
The patient and her friends can hardly be expected to appreciate the 
fact that it is often far from easy to give a positive opinion on the 
point ; and it is always advisable to use much caution in the examina- 
tion, and not to commit ourselves to a positive opinion, except on the 
most certain grounds. This is all the more important because it is 
just in those cases in which our opinion is most frequently asked that 
the statements of the patient are of least value, as she is either 
anxious to conceal the existence of pregnancy, or, if desirous of an 
affirmative diagnosis, unconsciously colors her statements so as to bias 
the judgment of the examiner. 

Classification. — Constant attempts have been made to classify the 
signs of pregnancy ; thus some divide them into the natural and 
sensible signs, others into the presumptive, the probable, and the certain. 
The latter classification, which is that adopted by Montgomery in his 
classical work on the Signs and Symptoms of Pregnancy, is no doubt 
the better of the two, if any be required. The simplest way of 
studying the subject, however, is the one, now generally adopted, of 
considering the signs of pregnancy in the order in which they occur, 
aod attaching to each an estimate of its diagnostic value. 

Signs of a Fruitful Conception. — From the earliest ages authors 
have thought that the occurrence of conception might be ascertained 
by certain obscure signs, such as a peculiar appearance of the eyes, 
swelling of the neck, or by unusual sensations connected with a 
fruitful intercourse. All of these, it need hardly be said, are far too 
uncertain to be of the slightest value. The last is a symptom on whicli 
manv married women profess themselves able to depend, and one to 
which Cazeaux is inclined to attach some importance. 

The first appreciable indication of pregnancy on which any depend- 
ence can be placed is the cessation of the customary menstrual dis- 
charge, and it is of great importance, as forming the only reliable 
guide for calculating the probable period of delivery. In women who 
have been previously perfectly regular, in whom there is no morbid 
cause which is likely to have produced suppression, the non-appearance 
of the catamenia may be taken as strong presumptive evidence of the 
existence of pregnancy ; but it can never be more than this, unless 
verified and strengthened by other signs, inasmuch as there are many 
conditions besides pregnancy which may lead to its non-appearance. 



152 PREGNANCY. 

Tli as exposure to cold, mental emotion, general debility, especially 
when connected with incipient phthisis, may all have this effect. 
Mental impressions are peculiarly liable to mislead in this respect. 
It is far from uncommon in newly-married women to find that men- 
struation ceases for one or more periods, either from the general dis- 
turbance of the system connected with the married life, or from a 
desire on the part of the patient to find herself pregnant. Also in 
unmarried women who have subjected themselves to the risk of 
impregnation, mental emotion and alarm often produce the same 
result. 

A further source of uncertainty exists in the fact that in certain 
cases menstruation may go on for one or more periods after conception, 
or even during the whole pregnancy. The latter occurrence is cer- 
tainly of extreme rarity, but one or two instances are recorded by 
Perfect, Churchill, and other writers of authority, and therefore its 
possibility must be admitted. The former is much less uncommon, 
and instances of it have probably come under the observation of most 
practitioners. The explanation is now well understood. During the 
early months of gestation, when the ovum is not yet sufficiently 
advanced in growth, to fill the whole uterine cavity, there is a consider- 
able space between the decidua reflexa which surrounds it and the 
decidua vera lining the uterine cavity. It is from this free surface of 
the decidua vera that the periodical discharge comes, and there is not 
only ample surface for it to come from, but a free channel for its 
escape through the os uteri. After the third month the decidua reflexa 
and the decidua vera blend together, and the space between them dis- 
appears. Menstruation after this time is, therefore, much more diffi- 
cult to account for. It is probable that, in many supposed cases, 
occasional losses of blood from other sources, such as placenta prsevia, 
an abraded cervix uteri, or a small polypus, have been mistaken for 
true menstruation. If the discharge really occurs periodically after 
the third month, it can only come from the canal of the cervix. The 
occurrence, however, is so rare, that if a woman is menstruating 
regularly and normally who believes herself to be more than four 
months advanced in pregnancy, we are justified ipso facto in negativing 
her supposition. In an unmarried woman all statements as to regu- 
larity of menstruation are absolutely valueless, for in such cases 
nothing is more common than for the patient to make false statements 
for the express purpose of deception. 

Conception may unquestionably occur when menstruation is nor- 
mally absent. This is far from uncommon in women during lactation, 
when the function is in abeyance, and who therefore have no reliable 
data for calculating the true period of their delivery. Authentic cases 
are also recorded in which young girls have conceived before men- 
struation is established, and in which pregnancy has occurred after 
the change of life. 

Taking all these facts into account, we can only look upon the 
cessation of menstruation as a fairly presumptive sign of pregnancy in 
women in whom there is no clear reason to account for it, but one 
which is undoubtedly of great value in assisting our diagnosis. 



SIGNS AND SYMPTOMS OF PREGNANCY. 152 

Shortly after conception various sympathetic disturbances of the 
system occur, and it is only very exceptionally that these are not 
established. They are generally most developed in women of highly 
nervous temperament ; and they are, therefore, most marked in patients 
in the upper classes of society, in whom this class of organization is 
most common. 

Morning" Sickness. — Amongst the most frequent of these are vari- 
ous disorders of the gastro-intestinal canal. Nausea or vomiting is very 
common ; and as it is generally felt on first rising from the recumbent 
position, it is commonly known amongst women as the " morning 
sickness. 7 ' It sometimes commences almost immediately after concep- 
tion, but more frequently not until the second month, and it rarely 
lasts after the fourth month. Generally there is nausea rather than 
actual vomiting. The woman feels sick and unable to eat her break- 
fast, and often brings up some glairy fluid. In other cases she actually 
vomits ; and sometimes the sickness is so excessive as to resist all 
treatment, seriously to affect the patient's health, and even imperil 
her life. These grave forms of the affection will require separate 
consideration. 

Very different opinions have been held as to the cause of morning 
sickness. Henry Benuet believed that, when at all severe, it is always 
associated with congestion and inflammation of the cervix uteri. Graily 
Hewitt maiutains that it depends entirely on flexion of the uterus pro- 
ducing irritation of the uterine nerves at the seat of the flexion, and 
consequent sympathetic vomiting. This theory, when broached at the 
Obstetrical Society, was received with little favor ; it seems to me to 
be sufficiently disproved by the fact that more or less nausea is a very 
common phenomenon in pregnancy. Out of 300 pregnancies Giles 1 
found that 200 were accompanied by vomiting, and it is difficult to 
believe that two pregnant women out of three have a flexed uterus. 
The generally received explanation is probably the correct one, viz., 
that nausea, as well as other forms of sympathetic disturbance, depend 
on the stretching of the uterine fibres, by the growing ovum, and con- 
sequent irritation of the uterine nerves. It is, therefore, one, and only 
one of the numerous reflex phenomena naturally accompanying preg- 
nancy. It is an old observation that when the sickness of pregnancy 
is entirely absent, other, and generally more distressing, sympathetic 
derangements are often met with, such as a tendency to syncope, or to 
asthma. Dr. Bedford 2 has laid especial stress on this point, and maiu- 
tains that under such circumstances women are peculiarly apt to mis- 
carry. 

Other derangements of the digestive functions, depending on the 
same cause, are not uncommon, such as excessive or depraved appetite, 
the patient showing a craving for strange and even disgusting articles 
of diet. These cravings may be altogether irresistible, and are popu- 
larly known as " longings." Of a similar character is the disturbed 
condition of the bowels frequently observed, leading to constipation, 
diarrhoea, and excessive flatulence. 

i Obstet. Trans., 1894. * Diseases of Women and Children, p. 551. 



154 PREGNANCY. 

Certain glandular sympathies may be developed, one of the most 
common being an excessive secretion from the salivary glands. A 
tendency to syncope is not unfrequent, rarely proceding to actual 
fainting, but rather to that sort of partial syncope, unattended with 
complete loss of consciousness, which the older authors used to call 
" leipothymia." This often occurs in women who show no such 
tendency at other times, and, when developed to any extent, it forms 
a very distressing accompaniment of pregnancy. Toothache is com- 
mon, and is not rarely associated with actual caries of the teeth. 
When any of these phenomena are carried to excess it is more than 
probable that some morbid condition of the uterus exists, which 
increases the local irritation producing them. 

Mental Peculiarities. — Mental phenomena are very general. An 
undue degree of despondency, utterly beyond the patient's control, is 
far from uncommon ; or a change which renders the bright and good- 
tempered woman fractious and irritable ; or even the more fortunate, 
but less common, change, by which a disagreeable disposition becomes 
altered for the better. 

All these phenomena of exalted nervous susceptibility are but of 
slight diagnostic value. They may be taken as corroborating more 
certain signs, but nothing more ; and they are chiefly interesting 
from their tendency to be carried to excess and to produce serious 
disorders. 

Certain changes in the mamrnse are of early occurrence, dependent, 
no doubt, on the intimate sympathetic relations at all times existing 
between them and the uterine organs, but chiefly required for the 
purpose of preparing for the important function of lactation, which, 
on the termination of pregnancy, they have to perform. 

Generally about the second month of pregnancy the breasts become 
increased in size, and tender. As pregnancy advances they become 
much larger and firmer, the enlargement being caused by growth both 
of connective and glandular tissue, and blue veins may be seen cours- 
ing over them. The most characteristic changes are about the nipples 
and areolae. The nipples become turgid, and are frequently covered 
with minute branny scales, formed by the desiccation of sero-lactescent 
fluid oozing from them. The areolae become greatly enlarged and 
darkened from the deposit of pigment (Fig. 77). The extent and 
degree of this discoloration vary much in different women. In fair 
women it may be so slight as to be hardly appreciable ; while in dark 
women it is generally exceedingly characteristic, sometimes forming a 
nearly black circle extending over a great part of the breast. The areola 
becomes moist as well as dark in appearance, is somewhat swollen, 
and a number of small tubercles are developed upon it, forming a 
circle of projections round the nipple. These tubercles are described 
by Montgomery as being intimately connected with the lactiferous 
ducts, some of which may occasionally be traced into them and seem 
to open on their summits. As pregnancy advances they increase in 
size and number. During the latter months what has been called 
"the secondary areola" is produced, and when well marked presents 
a very characteristic appearance. It consists of a number of minute 



SIGNS AND SYMPTOMS OF PREGNANCY, 



155 



discolored spots all round the outer margin of the areola where the 
pigmentation is fainter, and which are generally described as resem- 
bling spots from which the color has been discharged by a shower of 
water-drops. This change, like the darkening of the primary areola, 
is more marked in brunettes. At this period, especially in women 
whose skin is of fine texture, whitish silvery streaks are often seen on 
the breasts. They are produced by the stretching of the cutis vera, 
and are permanent. 

By pressure on the breasts a small drop of serous-looking fluid can 
very generally be forced out from the nipple, often as early as the 
third month, and on microscopic examination milk and colostrum 
globules can be seen in it. 

Fig. 77. 




Appearance of the areola in pregnancy. 

The diagnostic value of these mammary changes has been variously 
estimated. When well marked they are considered by Montgomery 
to be certain signs of pregnancy. To this statement, however, some 
important limitations must be made. In women who have never 
borne children they, no doubt, are so ; for, although various uterine 
and ovarian diseases produce some darkening of the areola, they cer- 
tainlv never produce the well-marked changes above described. In 
multipara?, however, the areola? often remain permanently darkened, 
and in them these signs are much less reliable. In first pregnancies 
the presence of milk in the breasts may be considered an almost cer- 
tain sign, and it is one which I have rarely failed to detect even from 
a comparatively early period. It is true that there are authenticated 
instances of non-pregnant women having an abundant secretion of 
milk established from mammary irritation. Thus Baudelocque pre- 
sented to the Academy of Surgery of Paris a young girl, eight years 



156 PKEGNANCY. 

of age, who had nursed her little brother for more than a month. 
Dr. Tanner states — I do not know on what authority — that " it is not 
uncommon in Western Africa for young girls who have never been 
pregnant to regularly employ themselves in nursing the children of 
others, the mamm?e being excited to action by the application of the 
juice of one of the Euphorbiacese." Lacteal secretion has even been 
noticed in the male breast. But these exceptions to the general rule 
are so uncommon as merely to deserve mention as curiosities ; and I 
have hardly ever been deceived in diagnosing a first pregnancy from 
the presence of even the minutest quantity of lacteal secretion in the 
breasts, although even then other corroborative signs should always 
be sought for. In multipara? the presence of milk is by no means so 
valuable, for it is common for milk to remain in the mamma? long 
after the cessation of lactation, even for several years. Tyler Smith 
correctly says that " suppression of the milk in persons who are 
nursing and liable to impregnation is a more valuable sign of preg- 
nancy than the converse condition." This is an observation I have 
frequently corroborated. 

As a diagnostic sign, therefore, the mammary appearances are of 
great importance in primiparse, and when well marked they are seldom 
likely to deceive. They are specially important when we suspect 
pregnancy in the unmarried, as we can easily make an excuse to look 
at the breast without explaining to the patient the reason ; and a 
single glance, especially if the patient be dark-complexioned, may 
so far strengthen our suspicion as to justify a more thorough examina- 
tion. In married multipara? they are less to be depended upon. 

In connection with this subject may be mentioned various irregular 
deposits of pigment which are frequently observed. The most com- 
mon is a dark-brownish or yellowish line starting from the pubes and 
running up the centre of the abdomen, sometimes as far as the um- 
bilicus only, at others forming an irregular ring around the umbilicus, 
and reaching to the epigastrium. It is, however, of very uncertain 
occurrence, being well marked in some women, while in others it is 
entirely absent. Patches of darkened skin are often observed about 
the face, chiefly on the forehead, and this bronzing sometimes gives a 
very peculiar appearance. Joulin states that it only occurs on parts 
of the face exposed to the sun, and that it is therefore most fre- 
quently observed in women of the lower orders who are freely exposed 
to atmospheric influences. These pigmentary changes are of small 
diagnostic value, and may continue for a considerable time after de- 
livery. 

The progressive enlargement of the abdomen, and the size of the 
gravid uterus at various periods of pregnancy, as well as the method 
of examination by means of abdominal palpation, have already been 
described (pp. 131 and 139-141). Noble 1 attaches great importance 
to the altered shape of the corpus uteri as a diagnostic sign of preg- 
nancy during the first three months (p. 143). 

Foetal Movements. — We will now consider the well-known phe« 

i Transactions of the Philadelphia Medical Society, 1894. 



SIGNS AND SYMPTOMS OF PREGNANCY. 157 

nomena produced by the movements of the foetus in utero, which are 
so familiar to all pregnant women. These, no doubt, take place from 
the earliest period of foetal life at which the muscular tissue of the 
foetus is sufficiently developed to admit of contraction, but they are 
not felt by the mother until somewhere about the sixteenth week of 
utero-gestation, the precise period at which they are perceived varying 
considerably in different eases. The error of the law on this subject, 
which supposes the child not to be alive, or " quick," until the mother 
feels its movements, is well known, and has frequently been protested 
against by the medical profession. The so-called quickening — which 
certainly is felt very suddenly by some women — is believed to depend 
on the rising of the uterine tumor sufficiently high to permit of the 
impulse of the foetus being transmitted to the maternal abdominal walls, 
through the sensory nerves of which its movements become appreci- 
able. The sensation is generally described as being a feeble flutter- 
ing, which, when first felt, not unfrequently causes unpleasant 
nervous sensations. As the uterus enlarges, the movements become 
more and more distinct, and generally consist of a series of sharp 
blows or kicks, sometimes quite appreciable to the naked, eye, and 
causing distinct projections of the abdominal walls. Their force and 
frequency will also vary during pregnancy according to circumstances. 
At times they are very frequent and distressing ; at others, the foetus 
seems to be comparatively quiet, and they may even not be felt for 
several days in succession, and thus unnecessary fears as to death 
of the foetus often arise. The state of the mother's health has an 
undoubted influence upon them. They are said to increase in force 
after a prolonged abstinence from food, or in certain positions of the 
body. It is certain that causes interfering with the vitality of the 
foetus often produce very irregular and tumultuous movements. They 
can be very readily felt by the accoucheur on palpating the abdomen, 
and sometimes, in the latter months, so distinctly as to leave no doubt 
as to the existence of pregnancy. They can also generally be induced 
by placing one hand on each side of the abdomen and applying 
gentle pressure, which ^svill induce foetal motion that can be easily 
appreciated. 

As a diagnostic sign the existence of foetal movements has always 
held a high place, but care should be taken in relying on it. It is 
certain that women are themselves very often in error, and fancy they 
feel the movements of a foetus when none exists, being probably 
deceived by irregular contractions of the abdominal muscles, or by 
flatus within the bowels. They may even involuntarily produce such 
intra-abdominal movements as may readily deceive the practitioner. 
Of course, in advanced pregnancy, when the foetal movements are so 
marked as to be seen as well as felt, a mistake is hardly possible, and 
they then constitute a certain sign. But in such cases there is an 
abundance of other indications and little room for doubt. In ques- 
tionable cases, and at an early period of pregnancy, the fact that move- 
ments are not felt must not be taken as a proof of the non-existence 
of pregnancy, for they may be so feeble as not to be perceptible, or 
they may be absent for a considerable period. 



158 PREGNANCY. 

Braxton Hicks 1 has directed attention to the value, from a diagnostic 
point of view, of intermittent contractions of the uterus during preg- 
nane v. After the uterus is sufficiently large to be felt by palpation, 
if the hand be placed over it, and it be grasped for a time without 
using any friction or pressure, it will be observed to distinctly harden 
in a manner that is quite characteristic. This intermittent contraction 
occurs every five or ten minutes, sometimes oftener, rarely at longer 
intervals. The fact that the uterus does contract in this way had been 
previously described, more especially by Tyler Smith, who ascribed it 
to peristaltic action. But it is certain that no one, before Dr. Hicks, 
had pointed out the fact that such contractions are constant and 
normal concomitants of pregnancy, continuing during the Avhole 
period of utero-gestation, and forming a ready and reliable means of 
distinguishing the uterine tumor from other abdominal enlargements. 
Since reading Dr. Hicks's paper I have paid considerable attention to 
this sign, which I have never failed to detect, even in the retroverted 
gravid uterus contained entirely in the pelvic cavity, and I am dis- 
posed entirely to agree with him as to its great value in diagnosis. If 
the hand be kept steadily on the uterus, its alternate hardening and 
relaxation can be appreciated with the greatest ease. The advantages 
which this sign has over the foetal movements are that it is constant, 
that it is not liable to be simulated by anything else, and that it is 
independent of the life of the child, being equally appreciable when 
the uterus contains a degenerated ovum or dead foetus. The only con- 
dition likely to give rise to error is an enlargement of the uterus in 
consequence of contents other than the results of conception, such as 
retained menses, or a polypus. The history of such cases — which are, 
moreover, of extreme rarity — would easily prevent any mistake. As 
a corroborative sign of pregnancy, therefore, I should give these in- 
termittent contractions a high place. 

The vaginal signs of pregnancy are of considerable importance 
in diagnosis. They are chiefly the changes which may be detected in 
the cervix, and the so-called ballottement, which depends on the mobility 
of the foetus in the liquor amnii. 

Softening of the Cervix. — The alterations in the density and 
apparent length of the cervix have been already described (p. 143). 
When pregnancy has advanced beyond the fifth month the peculiar 
velvety softness of the cervix is very characteristic, and affords a strong 
corroborative sign, but one which it would be unsafe to rely on by 
itself, inasmuch as very similar alterations may be produced by various 
causes. When, however, in a supposed case of pregnancy advanced 
beyond the period indicated, the cervix is found to be elongated, dense, 
and projecting into the vaginal canal, the non-existence of pregnancy 
may be safely inferred. Therefore the negative value of this sign is 
of more importance than the positive. In connection with this may 
be mentioned a sign of pregnancy to which attention has recently 
been drawn by Hegar. 2 It consists in a peculiar elasticity of the 

i Obst. Trans., 1872, vol. xiii. p. 216. 

2 Centralblatt fur Gynak., 1887, Bd. xi. S.'805. 



SIGNS AND SYMPTOMS OF PREGNANCY. 159 

lower segments of the uterus, made out by vaginal or rectal examina- 
tion. It may serve to differentiate the pregnant uterus from certain 
uterine enlargements due to tumor in cases in which the diagnosis is 
doubtful. 

Ballottement, when distinctly made out, is a very valuable indica- 
tion of pregnancy. It consists in the displacement, by the examining 
finger, of the foetus, which floats up in the liquor amnii, and falls back 
again on the tip of the finger with a slight tap which is exceedingly 
characteristic. 

In order to practise it most easily, the patient is placed on a couch 
or bed in a position midway between sitting and lying, by which the 
vertical diameter of the uterine cavity is brought into correspondence 
with that of the pelvis. Two fingers of the right hand are then passed 
high up into the vagina in front of the cervix. The uterus being now 
steadied from without by the left hand, the intra-vaginal fingers press 
the uterine wall suddenly upward, when, if pregnancy exist, the foetus 
is displaced, and in a moment falls back again, imparting a distinct 
impulse to the fingers. When easily appreciable it may be considered 
as a certain sign, for although an anteflexed fundus, or a calculus in 
the bladder, may give rise to somewhat similar sensations, the absence 
of other indications of pregnancy would readily prevent error. Bal- 
lottement is practised between the fourth and seventh months. Before 
the former time the foetus is too small, while at a later period it is 
relatively too large, and can no longer be easily made to rise upward 
in the surrounding liquor amnii. The absence of ballottement must 
not be taken as proving the non-existence of pregnancy, for it may be 
inappreciable from a variety of causes, such as abnormal presentations, 
or the implantation of the placenta upon the cervix uteri. 

Vaginal Pulsation. — There are also some other vaginal signs of 
pregnancy of secondary consequence. Amongst these is the vaginal 
pulsation pointed out by Osiander resulting from the enlargement of 
the vaginal arteries, which may sometimes be felt beating at an early 
period. Often this pulsation is very distinct, at other times it cannot 
be felt at all, and it is altogether unreliable, as a similar pulsation may 
be felt in various uterine diseases. 

Uterine Fluctuation. — Dr. Rasch has drawn attention to a pre- 
viously undescribed sign which he believes to be of importance in the 
diagnosis of early pregnancy. 1 It consists in the detection of fluctua- 
tion, through the anterior uterine wall, depending on the presence of 
the liquor amnii. In order to make this out, two fingers of the right 
hand must be used, as in ballottement, while the uterus is steadied 
through the abdomen. Dr. Rasch states chat by this means the en- 
larged uterus in pregnancy can easily be distinguished from enlarge- 
ment depending on other causes, and that fluctuation can always be 
felt as early as the second month. If it is associated with suppressed 
menstruation and darkened areolae, he considers it a certain sign. In 
order to detect it, however, considerable experience in making vaginal 
examinations is essential, and it can hardly be depended on for gen- 
eral use. 

1 Brit. Med. Journ , 1873, vol. ii. p. 261. 



160 PREGNANCY. 

A peculiar deep violet hue of the vagiual mucous membrane was 
relied on by Jacquemin 1 aud Kluge as affording a readily observed 
indication of pregnancy. In most cases it is well marked ; sometimes, 
indeed, the change of color is very intense, and it evidently depends 
on the congestion produced by pressure of the enlarged uterus. Chad- 
wick has reinvestigated this sign, and attributes to it a high diagnostic 
value. 2 It has been generally stated to be unreliable, as a similar dis- 
coloration is said to be produced by the pressure of large uterine 
fibroids. This, however, Chadwick declares is not the case. 

Auscultatory Signs of Pregnancy. — By far the most important 
signs are those which can be detected by abdominal auscultation, and 
one of these — the hearing of the foetal heart-sounds — forms the only 
sign which per se, and in the absence of all others, is perfectly reliable. 

The fact that the sounds of the foetal heart are audible during ad- 
vanced pregnancy was first pointed out by Mayor, of Geneva, in 1818, 
and the main facts in connection with foetal auscultation were subse- 
quently worked out by Kergaradec, Naegele, Evory Kennedy, and 
other observers. The pulsations first become audible, as a rule, in the 
course of the fifth month, or about the middle of the fourth month. 
In exceptional circumstances, and by practised observers, they have 
been heard earlier. Depaul believes that he detected them as early as 
the eleventh week, and Routh has also detected them at an earlier 
period by vaginal stethoscopy, which, however, for obvious reasons, 
cannot be ordinarily employed. JNTaegele never heard them before the 
eighteenth week, more generally at the end of the twentieth, and for 
practical purposes the pregnancy must be advanced to the fifth month 
before we can reasonably expect to detect them. From this period up 
to term they can almost always be heard to a certainty, if not at the 
first attempt, at least afterward, if we have the opportunity of making 
repeated examinations. Accidental circumstances, such as the presence 
of an unusual amount of flatus in the intestines, may deaden the 
sounds for a time, but not permanently. Depaul only failed to hear 
them in 8 cases out of 906 examined during the last three months of 
pregnancy; and out of 180 cases which Dr. Anderson, of Glasgow, 
carefully examined, he only failed in 12, and in each of these the child 
was stillborn. They, therefore, form not only a most certain indication 
of pregnancy, but of the life of the foetus also. 

The sound has always been likened to the double tic-tac of a watch 
heard through a pillow, which it closely resembles. It consists of two 
beats, separated by a short interval, the first being the loudest and 
most distinct, the second being sometimes inaudible. The rapidity of 
the foetal pulsations forms an important means of distinguishing them 
from transmitted maternal pulsations with which they might be con- 
founded. Their average number is stated by Slater, who made numer- 
ous observations on this point, to be 132, but sometimes they reach as 
high as 140, and sometimes as low as 120. It will thus be seen that 

1 The credit of first drawing attention to this sign of pregnancy is generally given to Jacquemler, 
a distinguished French obstetrician, who wrote a work on Midwifery. It is due, however, to 
Jacquemin, medecin en chef de la prison de Mazas, and is, in fact, attributed to him in Jacquemier's 
work (Manuel des Accoucheraents, par J. Jacquemier, Paris, 1846, vol. i. p. 215). 

2 Transactions of the American Gynecological Society, 1886, vol. ii. p. 399. 



SIGNS AND SYMPTOMS OF PREGNANCY. 161 

the pulsations are always much more rapid than those of the mother's 
heart, unless, indeed, the latter be unduly accelerated by transient 
mental emotion or disease. To avoid mistakes, whenever the foetal 
heart is heard its rate of pulsation should be carefully counted, and 
compared with that of the mother's pulse ; if the rate differ, we may 
be sure that no error has been made. The rapidity of the foetal pulsa- 
tions remains, as a rule, the same during the whole period of preg- 
nancy, while their intensity gradually increases. They may, however, 
be temporarily increased or diminished in frequency by disturbing 
causes, such as the pressure of the stethoscope, which, exciting 
tumultuous movements of the foetus, may induce greatly increased 
frequency of its heart-beats. So also they may be greatly modified 
during labor, after the escape of the liquor amnii, when the contrac- 
tions of the uterus have a very distinct influence on the foetus. An 
acceleration or irregularity of the pulsations, made out in the course 
of a prolonged labor, may thus be of great practical importance, by 
indicating the necessity for prompt interference. Similar alterations, 
associated with tumultuous and unusual foetal movements felt by the 
mother toward the end of pregnancy, may point to danger to the life 
of the foetus during the latter months, and may even justify the induc- 
tion of premature labor. This is especially the case in women who 
have previously given birth to a succession of dead children owing 
to disease of the placenta, and, in them, careful and frequently 
repeated auscultations may warn us of the impending danger. 

The rapidity of the foetal heart has been supposed by some to afford 
a means of determining the sex of the child before birth. Franken- 
hauser, who first directed attention to this point, is of opinion that the 
average rate of pulsations of the heart is considerably less in male than 
in female children, averaging 124 in the minute in the former, as 
against 144 in the latter. Steinbach makes the difference somewhat 
less, viz., 131 for males and 138 for females. He predicted the sex 
correctly by this means in 45 out of 57 cases, while Frankenhauser 
was correct in the whole 50 cases which he specially examined with 
reference to the point. Dr. Hutton, of New York, 1 was also correct 
in 7 cases which he fixed on for trial. Devilliers found the difference 
in the sexes to be the same as Steinbach ; he attributes it, however, 
to the size and weight rather than to the sex of the child, and believes 
the pulsations to be least numerous in large and well-developed chil- 
dren. As male children are usually larger than female, he thus 
explains the relatively less frequent pulsations of their hearts. Dr. 
Gumming, of Edinburgh, also believes that the weight of the child has 
considerable influence on the frequency of its cardiac pulsations, so 
that a large female child may have a slower pulse than a small male. 2 
The point, however, is more curious than practical, and the rapidity 
of the pulsations certainly would not justify any positive prediction 
on the subject. Circumstances influencing the maternal circulation 
seem to have no influence on that of the foetus. 

The foetal heart-sounds are generally propagated best by the back 

i New York Med. Journ., 1872, vol. xvi. p. 68. 

2 E'lin. Med. Journ., vol. 1*7'>-7G, pp. 230, 317, 418. 



162 PREGNANCY. 

of the child, and are, therefore, most easily audible when this is in 
contact with the anterior Avail of the uterus, as is the case in the large 
majority of pregnancies. When the child is placed in the dorso- 
posterior position, the sounds have to traverse a larger amount of the 
liquor ainnii, and are further modified by the interposition of the foetal 
limbs. They are, therefore, less easily heard in such cases, but even 
in them they can almost always be made out. As the foetus most 
frequently lies with the occiput over the brim of the pelvis, and the 
back of the child toward the left side of the mother, the heart-sounds 
are usually most distinctly audible at a point midway between the 
umbilicus and the left anterior superior spine of the ilium. In the 
next most common position, in which the back of the child lies to 
the right lumbar region of the mother, they are generally heard at a 
corresponding point at the right side, but in this case they are fre- 
quently more readily made out in the right flank, being then trans- 
mitted through the thorax of the child, which is in contact with the 
side of the uterus. In breech cases, on the other hand, the heart- 
sounds are generally heard most distinctly above the umbilicus, and 
either to the right or left, according to the side toward which the back 
of the child is placed. It will thus be seen that the place at which 
the foetal heart-sounds are heard varies with the position of the foetus ; 
and this, when combined with the information derived from palpation, 
affords a ready means of ascertaining the presentation of the child 
before labor. The sounds are only audible over a limited space, 
about two or three inches in diameter ; therefore, if we fail to detect 
them in one place, a careful exploration of the whole uterine tumor is 
necessary before we are satisfied that they cannot be heard. 

The only mistake that is likely to be made is taking the maternal 
pulsations, transmitted through the uterine tumor, for those of the 
foetal heart. A little care will easily prevent this error, and the fre- 
quency of the mother's pulse should always be ascertained before 
counting the supposed foetal pulsations. If these are found to be 120 
or more, while the mother's pulse is only 70 or 80, no mistake is 
possible. If the latter is abnormally quickened greater care may be 
necessary, but even then the rate of pulsation of each will be dis- 
similar. Braxton Hicks 1 has pointed out that in tedious labor, when 
the muscular powers of the mother are exhausted, the muscular sub- 
surrus may produce a sound closely resembling the foetal pulsation ; 
but error from this source is obviously very improbable. 

In listening for the foetal heart-sounds the patient should be placed 
on her back, with the shoulders elevated and the knees flexed. The 
surface of the abdomen should be uncovered, and an ordinary stetho- 
scope employed, the end of which must be pressed firmly on the 
tumor, so as to depress the abdominal walls. The most absolute still- 
ness is necessary, as it is often far from easy to hear the sounds. 
Sometimes, after failing with the ordinary stethoscope, I have suc- 
ceeded with the binaural, which remarkably intensifies them. When 
once heard they are most easily counted during a space of five seconds, 

» Obst. Trans., 1874, vol. xv. p. 187. 



SIGNS AND SYMPTOMS OF PREGNANCY. 163 

as, on account of their frequency, it is not always possible to follow 
them over a longer period. 

When the foetal heart-sounds are heard distinctly, pregnancy may 
be absolutely and certainly diagnosed. The fact that we do not hear 
them does not, however, preclude the possibility of gestation, for the 
foetus may be dead, or the sounds temporarily inaudible. 

Other Sounds heard in Pregnancy. — There are some other sounds 
heard in auscultation which are of very secondary diagnostic value. 
One of these is the so-called umbilical or funic souffle, which was first 
pointed out by Evory Kennedy. It consists of a single blowing 
murmur, synchronous with the foetal heart-sounds, and most distinctly 
heard in the immediate vicinity of the point where these are most 
audible. Most authors believe it to be produced by pressure on the 
cord, either when it is placed between a hard part of the foetus and 
the uterine walls, or is twisted around the child's neck. Schroeder 
and Hecker detected it in fourteen or fifteen per cent, of all cases, and 
the latter believed it to be caused by flexure of the first portion of the 
cord near the umbilicus. For practical purposes it is quite valueless, 
and need only be mentioned as a phenomenon which an experienced 
auscultator may occasionally detect. 

The uterine souffle is a peculiar single whizzing murmur which is 
almost always audible on auscultation. It varies very remarkably in 
character and position. Sometimes it is a gentle blosving or even 
musical murmur ; at others it is loud, harsh, and scraping ; sometimes 
continuous, sometimes intermittent. It may also be heard at any 
point of the uterus, but most frequently low down, and to one or other 
side ; more rarely above the umbilicus, or toward the fundus ; and it 
often changes its position so as to be heard at a subsequent ausculta- 
tion at a point where it was previously inaudible. It may be heard 
over a space of an inch or two only, or in some cases over the whole 
uterine tumor ; or again, it may sometimes be detected simultaneously 
over two entirely distinct portions of the uterus. It is generally to 
be heard earlier than the foetal heart-sounds, often as soon as the 
uterus rises above the brim of the pelvis, and it can almost always be 
detected after the commencement of the fourth month. The sound 
becomes curiously modified by the uterine contractions during labor, 
becoming louder and more intense before the pain comes on, disappear- 
ing during its acme, and again being heard as it goes off. Hicks 
attributes to a similar cause, viz., the uterine contractions during 
pregnancv, the frequent variations in the sound which are character- 
istic of it. 1 The uterine souffle is also audible after the death of the 
foetus, and it is believed by some to be modified and to become more 
continuously harsh when that event has taken place. 

Very various explanations have been given of the causes of this 
sound. For long it was supposed to be formed in the vessels of the 
placenta, and hence the name u placental souffle" by which it is often 
talked of; or if not in the placenta, in the uterine vessels in its imme- 
diate neighborhood. The non-placental origin of the sound is suffi- 

i Op. cit., p. 2-23. 



164 PEEGNANCY. 

ciently demonstrated by the fact that it may be heard for a considerable 
time after the expulsion of the placenta. Some have supposed that it 
is not formed in the uterus at all, but in the maternal vessels, especially 
the aorta and the iliac arteries, owing to the pressure to which they 
are subjected by the gravid uterus. The extreme irregularity of the 
sound, its occasional disappearance, and its variable site, seem to be 
conclusive against this view. The theory which refers the sound to 
the uterine vessels is that which has received most adherents, and 
which best meets the facts of the case ; but it is by no means easy, or 
even possible, to account for the exact mode of its production in them. 
Each of the explanations which have been given is open to some 
objection. It is far from unlikely that the intermittent contractions 
of the uterine fibres, which are known to occur during the whole 
course of pregnancy, may have much to do with it, by modifying, at 
intervals, the rapidity of the circulation in the vessels. Its production 
in this manner may also be favored by the chlorotic state of the blood, 
to which Cazeaux and Scanzoni are inclined to attribute an important 
influence, likening it to the anaemic murmur so frequently heard in the 
vessels in weakly women. 

From a diagnostic point of view the uterine souffle is of very 
secondary importance, because a similar sound is very generally 
audible in large fibroid tumors of the uterus, and even in some few 
ovarian tumors ; it is, therefore, of little or no value in assisting us to 
decide the character of the abdominal enlargement. The supposed 
dependence of the sound on the placental circulation has caused its 
site to be often identified with that of the placenta. It is, however, 
most frequently heard at the lower part of the uterus, while the 
placenta is generally attached near the fundus, so that its position 
cannot be taken as any safe guide in determining the situation of that 
organ. 

Occasionally, in practising auscultation, irregular sounds of brief 
duration may be heard, which are not susceptible of accurate descrip- 
tion, and which doubtless depend on the sudden movement of the 
foetus in the liquor amnii, or on the impact of its limbs on the uterine 
walls. When heard distinctly they are characteristic of pregnancy ; 
and they may be sometimes heard when the other sounds cannot be 
detected. They are, however, so irregular, and so often entirely absent, 
that they can hardly be looked upon in any other light than as occa- 
sional phenomena. 

Two other sounds have been described as being sometimes audible, 
which may be mentioned as matters of interest, but which are of no 
diagnostic value. One is a rustling sound, said by Stoltz to be audible 
in cases in which the foetus is dead, and which he refers to gaseous 
decomposition of the liquor amnii ; its existence is, however, extremely 
problematical. The other is a sound heard after the birth of the child, 
and referred by Caillant to the separation of the placental adhesions. 
He describes it as a series of rapid short scratching sounds, similar to 
those produced by drawing the nails across the seat of a horsehair 
sofa. Simpson 1 admitted the existence of the sound, but believed 

i Selected Obstet. Works, p. 15L 



SIGNS AND SYMPTOMS OF PREGNANCY. 165 

that it is produced by the mere physical crushing of the placenta, and 
artificially imitated it out of the body by forcing the placenta through 
an aperture the size of the os uteri. 

It will be seen, then, that although there are numerous signs and 
symptoms accompanying pregnancy, many of them are unreliable by 
themselves, and apt to mislead. Those which may be confidently 
depended on are the pulsations of the fcetal heart, which, however, 
foil us in cases of dead children ; the fcetal movements when distinctly 
made out ; ballottement ; the intermittent contractions of the uterus ; 
and to these we may safely add the presence of milk in the breasts, 
provided Ave have to do with a first pregnancy. 

The remainder are of importance in leading us to suspect pregnancy, 
and in corroborating and strengthening other symptoms, but they do 
not, of themselves, justify a positive diagnosis. 



CHAPTEE Y. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY.— SPURIOUS 
PREGNANCY.— THE DURATION OF PREGNANCY.— SIGNS OF 
RECENT PREGNANCY. 

The differential diagnosis of pregnancy has of late years assumed 
much importance on account of the advance of abdominal surgery. 
The cases are so numerous in which even the most experienced prac- 
titioners have fallen into error, and in which the abdomen has been 
laid open in ignorance of the fact that pregnancy existed, that the 
subject becomes one of the greatest consequence. Fortunately it is 
less so from an obstetrical than from a gynecological point of view, 
inasmuch as the converse error, of mistaking some other condition for 
pregnancy, is of far less consequence, as it is one which time will 
always rectify. But even in this way carelessness may lead to very 
serious injury to the character, if not to the health, of the patient ; 
and it will be well to refer briefly to some of the conditions most liable 
to be mistaken for pregnancy, and to the mode of distinguishing them. 

Adipose enlargement of the abdomen may obscure the diagnosis by 
preventing the detection of the uterus ; and if, as is not uncommon 
with women of great obesity, it is associated witli irregular menstrua- 
tion, the increased size of the abdomen might be supposed to depend 
on pregnancy. The absence of corroborative signs, such as auscultatory 
phenomena, mammary changes, and the hardness of the cervix as felt 
•per vaginam, make it easy to avoid this error. 

Distention of the uterus by retained menstrual fluid, or watery 
secretion, is an occurrence of rarity that could seldom give rise to 
error. Still, it occasionally happens that the uterus becomes enlarged 



166 PREGNANCY. 

in this way, sometimes reaching even to the level of the umbilicus, 
and that the physical character of the tumor is not unlike that of the 
gravid uterus. The best safeguard against mistakes will be the pre- 
vious history of the case, which will always be different from that of 
ordinary -pregnancy. Retention of the menses almost always occurs 
from some physical obstruction to the exit of the fluid, such as imper- 
forate hymen ; or if it occur in women who have already menstruated, 
we may usually trace a history of some cause, such as inflammation 
following an antecedent labor, which has produced occlusion of some 
part of the genital tract. The existence of a pelvic tumor in a girl 
who has never menstruated will of itself give rise to suspicion, as 
pregnancy under such circumstances is of extreme rarity. It will also 
be found that general symptoms have existed for a period of time 
considerably longer than the supposed duration of pregnancy as 
judged of by the size of the tumor. The most characteristic of them 
are periodic attacks of pain due to the addition, at each monthly 
period, to the quantity of retained menstrual fluid. Whenever, from 
any of these reasons, suspicion of the true character of the case has 
arisen, a careful vaginal examination will generally clear it up. In 
most cases the obstruction will be in the vagina, and is at once de- 
tected, the vaginal canal above it, as felt per rectum, being greatly 
distended by fluid ; and we may also find the bulging and imperforate 
hymen protruding through the vulva. The absence of mammary 
changes, and of ballottement, will materially aid us in forming a 
diagnosis. 

The engorged and enlarged uterus frequently met with in women 
suffering from uterine disease, might readily be mistaken for an early 
pregnancy, if it happened to be associated with amenorrheea. A little 
time would, of course, soon clear up the point, by showing that pro- 
gressive increase in size, as in pregnancy, does not take place. This 
mistake could only be made at an early stage of pregnancy, when a 
positive diagnosis is never possible. The accompanying symptoms 
— pain, inability to walk, and tenderness of the uterus on pressure — 
would prevent such an error. 

Ascites, per se, could hardly be mistaken for pregnancy ; for the 
uniform distention and evident fluctuation, the absence of any definite 
tumor, the site of resonance on percussion changing in accordance 
with alteration of the position of the woman, and the unchanged cer- 
vix and uterus, should be sufficient to clear up any doubt. Pregnancy 
may, however, exist with ascites, and this combination may be difficult 
to detect, and might readily be mistaken for ovarian disease associated 
with ascites. The existence of mammary changes, the presence of the 
softened cervix, ballottement, and auscultation — provided the sounds 
were not masked by the surrounding fluid — would afford the best 
means of diagnosing such a case. 

One of the most frequent sources of difficulty is the differential 
diagnosis of large abdominal tumors, either fibroid or ovarian, or of 
some enlargements due to malignant disease of the peritoneum or 
abdominal viscera. The most experienced have been occasionally 
deceived under such circumstances. As a rule, the presence of men- 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 167 

stmation will prevent error, as this generally continues in ovarian 
disease, while in fibroids it is often excessive. The character of the 
tumor — the fluctuation in ovarian disease, the hard nodular masses in 
fibroid — and the history of the case — especially the length of time 
the tumor has existed — will aid in diagnosis, while the absence of 
cervical softening (vide p. 144) and of auscultatory phenomena will 
further be of material value in forming a conclusion. Some of the 
most difficult cases to diagnose are those in which pregnancy compli- 
cates ovarian or fibroid disease. Then the tumor may more or less 
completely obscure the physical signs of pregnancy. The usual shape 
of the abdomen will generally be altered considerably, and we may 
be able to distinguish the gravid uterus, separated from the ovarian 
tumor by a distinct sulcus, or with the fibroid masses cropping out 
from its surface. Our chief reliance must then be placed in the altera- 
tion of the cervix, and in the auscultatory signs of pregnancy. 

Spurious Pregnancy. — The condition most likely to give rise to 
errors is that very interesting and peculiar state known as spurious 
-pregnancy, or pseudocyesis. In this, most of the usual phenomena of 
pregnancy are so strangely simulated that accurate diagnosis is often 
far from easy. There are hardly any of the more apparent svmptoms 
of pregnancy which may not be present in marked cases of this kind. 
The abdomen may become prominent, the areolae altered, menstrua- 
tion arrested, and apparent foetal motions felt ; and, unless suspicion is 
aroused, and a careful physical examination made, both the patient 
and the practitioner may easily be deceived. 

There is no period of the childbearing life in which spurious preg- 
nancy may not be met with, but it is most likely to occur in elderlv 
women about the climacteric period, when it is generally associated 
with ovarian irritation connected with the change of life ; or in 
younger women, who are either very desirous of finding themselves 
pregnant, or who, being unmarried, have subjected themselves to the 
chance of being so. In all cases the mental faculties have much to 
do with its production, and there is generally either very marked 
hysteria, or even a condition closely allied to insanity. Spurious 
pregnancy is by no means confined to the human race. It is w r ell 
known to occur in many of the lower animals. Harvey related in- 
stances in bitches, either after unsuccessful intercourse, or in connec- 
tion with their being in heat, even when no intercourse had occurred. 
In such cases the abdomen swelled, and milk appeared in the mammge. 
Similar phenomena are also occasionally met with in the cow. In 
these instances, as in the human female, there is probably some 
morbid irritation of the ovarian system. 

The physical phenomena are often very well marked. The apparent 
enlargement is sometimes very great, and it seems to be produced by 
a projection forward of the abdominal contents due to depression of 
the diaphragm, together with rigidity of the abdominal muscles, and 
may even closely simulate the uterine tumor on palpation. After the 
climacteric it is frequently associated, as Gooch pointed out, with an 
undue deposit of fat in the abdominal walls and omentum, so that 
there may be even some dulness on percussion, instead of resonance of 



168 PREGNANCY. 

the intestines. The foetal movements are curiously and exactly simu- 
lated, either by involuntary contractions of the abdominal walls, or 
by the movement of flatus in the intestines. The patient also gener- 
ally fancies that she suffers from the usual sympathetic disorders of 
pregnancy, and thus her account of her symptoms will still further 
tend to mislead. 

Not only may the supposed pregnancy continue, but, at what would 
be the natural term of delivery, all the phenomena of labor may 
supervene. Many authentic cases are on record in which regular 
pains came on, and continued to increase in force and frequency until 
the actual condition was diagnosed. Such mistakes, however, are only 
likely to happen when the statements of the patient have been received 
without further inquiry. When once an accurate examination has 
been made, error is no longer possible. 

We shall generally find that some of the phenomena of pregnancy 
are absent. Possibly menstruation, more or less irregular, may have 
continued. Examination per vaginam will at once clear up the case, 
by showing that the uterus is not enlarged, and that the cervix is 
unaltered. It may then be very difficult to convince the patient or 
her friends that her symptoms have misled her, and for this purpose 
the inhalation of chloroform is of great value. As consciousness is 
abolished, the semi-voluntary projection of the abdominal muscles is 
prevented, the large apparent tumor vanishes, and the bystanders can 
be readily convinced that none exists. As the patient recovers the 
tumor again appears. 

Duration of Pregnancy. — The duration of pregnancy in the human 
female has always formed a fruitful theme for discussion among ob- 
stetricians. The reasons which render the point difficult of decision 
are obvious. As the large majority of cases occur in married women, 
in whom intercourse occurs frequently, there is no means of knowing 
the precise period at which conception took place. The only datum 
which exists for the calculation of the probable date of delivery is the 
cessation of menstruation. It is quite possible, however, and indeed 
probable, that conception occurred, in a considerable number of in- 
stances, not immediately after the last period, but immediately before 
the proper epoch for the occurrence of the next. Hence, as the inter- 
val between the end of one menstruation and the commencement of 
the next averages twenty-five days, an error to that extent is always 
possible. Another source of fallacy is the fact, which has generally 
been overlooked, that even a single coitus does not fix the date of 
conception, but only that of insemination. It is well known that in 
many of the lower animals the fertilization of the ovule does not take 
place until several clays after copulation, the spermatozoa remaining in 
the interval in a state of active vitality within the genital tract. It 
has been shown by Marion Sims that living spermatozoa exist in the 
cervical canal in the human female some days after intercourse. It is 
very probable, therefore, that in the human female, as in the lower 
animals, a considerable but unknown interval occurs between insem- 
ination and actual impregnation, which may render calculations as to 
the precise duration of pregnancy altogether unreliable. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 169 

A large mass of statistical observations exist respecting the average 
duration of gestation, which have been drawn up and collated from 
numerous sources. It would serve no practical purpose to reprint the 
voluminous tables on this subject that are contained in obstetrical 
works. They are based on two principal methods of calculation. 
First, we have the length of time between the cessation of menstruation 
and delivery. This is found to vary very considerably, but the largest 
percentage of deliveries occurs between the 274th and 280th day after 
the cessation of menstruation, the average day being the 278th ; but, 
in individual instances, very considerable variations both above and 
below these limits are found to exist. Next we have a series of cases, 
from various sources, in which only one coitus was believed to have 
taken place. These are naturally always open to some doubt, but, on 
the whole, they may be taken as affording tolerably fair grounds for 
calculation. Here, as in the other mode of calculation, there are 
marked variations, the average length of time, as estimated from a 
considerable collection of cases, being 275 days after the single inter- 
course. It may, therefore, be taken as certain that there is no definite 
time which we can calculate on as being the proper duration of preg- 
nancy, and, consequently, no method of estimating the probable date 
of delivery on which we can absolutely rely. 

Methods of Predicting" the Probable Date of Delivery. — The 
prediction of the time at which the confinement may be expected is, 
however, a point of considerable practical importance, and one on 
which the medical attendant is always consulted. Various methods 
of making the calculation have been recommended. It has been 
customary in this country, according to the recommendation of Mont- 
gomery, to fix upon ten lunar months, or 280 days, as the probable 
period of gestation, and, as conception is supposed to occur shortly 
after the cessation of menstruation, to add this number of days to any 
day within the first week after the last menstrual period as the most 
probable period of delivery. As, however, 278 days is found to be 
the average duration of gestation after the cessation of menstruation, 
and as the method makes the calculation vary from 281 to 287 days, it 
is evidently liable to fix too late a date. Naegele's method was to count 
seven days from the first appearance of the last menstrual period, and 
then reckon backward three months as the probable date. Thus, if a 
patient last commenced to menstruate on August 10, counting in this 
way from August 17 would give May 17 as the probable date of the 
delivery. 

Matthews Duncan has paid more attention than anyone else to the 
prediction of the date of delivery. His method of calculating is based 
on the fact of 278 days being the average time between the cessation 
of menstruation and parturition ; and he claims to have had a greater 
average of success in his predictions than on any other plan. His 
rule is as follows : " Find the day on which the female ceased to 
menstruate, or the first day of being what she calls ' well.' Take that 
dav nine months forward as 275 — unless February is included, in 
which case it is taken as 273 — days. To this add three days in the 
former case, or five if February is in the count, to make up the 278. 



170 



PREGNANCY. 



This 278th day should then be fixed on as the middle of the week, or, 
to make the prediction more accurate, of the fortnight in which the 
confinement is likely to occur, by which means allowance is made for 
the average variation of either excess or deficiency." 

Various periodoscopes and tables for facilitating the calculation 
have been made. The periodoscope of Dr. Tyler Smith is very useful 
for reference in the consulting-room, giving at a glance a variety of 
information, such as the probable period of quickening, the dates for the 
induction of premature labor, etc. The following table, prepared by Dr. 
Protheroe Smith, is also easily read, and is very serviceable : 

Table for Calculating the Period of Utero-gestatton. 1 





Nine calendar months. 




Ten lunar months. 




From 


To 


Days. 
273 


To 


Days. 


January 


1 


September 30 


October 7 


280 


February- 


1 


October 31 


273 


November 7 


280 


March 


1 


November 30 


275 


December 5 


280 


April 


1 


December 31 


275 


January 5 


280 


May 


1 


January 31 


27G 


February 4 


280 


June 


1 


February 28 


273 


March 7 


280 


July 


1 


March 31 


274 


April 6 


280 


August 


1 


April 30 


273 


May 7 


280 


September 


1 


May 31 


273 


June 7 


280 


October 


1 


June 30 


273 


July 7 


280 


November 


1 


July 31 


273 


August 7 


280 


December 


1 


August 31 


274 


September 6 


280 



The date at which the quickening has been perceived is relied on 
by many practitioners, and still more by patients, in calculating the 
probable date of delivery, as it is generally supposed to occur at the 
middle of pregnancy. The great variations, .however, of the time at 
which this phenomenon is first perceived, and the difficulty which is 
so often experienced of ascertaining its presence with any certainty, 
render it a very fallacious guide. The only times at which the per- 
ception of quickening is likely to prove of any real value are when 
impregnation has occurred during lactation (when menstruation is 
normally absent), or when menstruation is so uncertain and irregular 
that the date of its last appearance cannot be ascertained. As quick- 
ening is most commonly felt during the fourth month, more frequently 
in its first than in its last fortnight, it may thus afford the only guide 
we can obtain, and that an uncertain one, for predicting the date of 
delivery. 

Is Protraction of Gestation Possible ? — From a medico-legal 
point of view the question of the possible protraction of pregnancy 
beyond the average time, and of the limits within which such pro- 
traction can be admitted, is of very great importance. The law on 
this point varies considerably in different countries. Thus, in France 
it is laid down that legitimacy cannot be contested until 300 days 

i The above obstetric "Ready Reckoner" consists of two columns, one of calendar, the other of 
lunar, months, and may be read as follows : A patient has ceased to menstruate on July 1 : her 
confinement may be expected at soonest about March 31 {the end of nine calendar months) ; or at 
latest on April 6 (the end of ten lunar months). Another has ceased to menstruate on January 20 ; 
her confinement may be expected on September 30, plus twenty days {the end of nine calendar 
months), at soonest ; or on October 7, plus twenty days {the end of ten lunar months), at latest. 






DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 171 

have elapsed from the death of the husband, or the latest possible 
opportunity for sexual intercourse. This limit is also adopted by 
Austria, while in Prussia it is fixed at 302 days. In England and 
America no fixed date is admitted, but while 280 days is admitted as 
the "legitimuni tempus pariendi," each case in which legitimacy is 
questioned is to be decided on its own merits. At the early part of 
the century the question was much discussed by the leading obstetricians 
in connection with the celebrated Gardner peerage case, and a con- 
siderable difference of opinion existed among them. Since that time 
many apparently perfectly reliable cases have been recorded, in which 
the duration of gestation was obviously much beyond the average, and 
in which all sources of fallacy were carefully excluded. 

Not to burden these pages with a number of cases, it may suffice to 
refer, as examples of protraction, to four well-known instances recorded 
by Simpson, 1 in which the pregnancy extended respectively to 336, 
332, 319, and 324 days after the cessation of the last menstrual period. 
In these, as in all cases of protracted gestation, there is the possible 
source of error that impregnation may have occurred just before the 
expected advent of the next period. Making an allowance of 23 days 
in each instance for this, we even then have a number of days much 
above the average, viz., 313, 309, 296, and 301. Numerous instances 
as curious may be found scattered through obstetric literature. Indeed, 
the experience of most acccoucheurs will parallel such cases, which 
may be more common than is generally supposed, inasmuch as they 
are only likely to attract attention when the husband has been sepa- 
rated from the wife beyond the average and expected duration of the 
pregnancy. 

The evidence in favor of the possible prolongation of gestation is 
greatly strengthened by what is known to occur in the lower animals. 
In some of these, as in the cow and the mare, the precise period of 
insemination is known to a certainty, as only a single coitus is per- 
mitted. Manv tables of this kind have been constructed, and it has 
been shown that there is in them a very considerable variation. In 
some cases in the cow it has been found that delivery took place 45 
days, and in the mare 43 days, after the calculated date. Analogy 
would go strongly to show that what is known to a certainty to occur 
in the lower animals may also take place in the human female. The 
fact, indeed, is now very generally admitted ; but we are still unable 
to fix, with any degree of precision, on the extreme limit to which 
protraction is possible. Some practitioners have given cases in which, 
on data which they believe to be satisfactory, pregnancy has been 
extremely protracted ; thus Meigs and Adler record instances which 
they believed to have been prolonged to over a year in one case, and 
over fourteen months in the other. These are, however, so problem- 
atical that little weight can be attached to them. On the whole, it 
would hardly be safe to conclude that pregnancy can go more than 
three or four weeks beyond the average time. This conclusion is jus- 
tified by the cases we possess in which pregnancy followed a single 
coitus, the longest of which was 295 (hy*. 

l Obstet. Memoirs, p. 84. 



172 PREGNANCY. 

Dr. Duncan 1 is inclined to refuse credence to every case of supposed 
protraction unless the size and weight of the child are above the 
average, believing that lengthened gestation must of necessity cause 
increased growth of the child. This point requires further investiga- 
tion, and it cannot be taken as proved that the foetus necessarily must 
be v large because it has been retained longer than usual in utero ; or, 
even if this be admitted, it may have been originally small, and so, at 
the end of the protracted gestation, be little above the average weight. 
There are, however, many cases which certainly prove that a prolonged 
pregnancy is at least often associated with an unusually developed 
foetus. Dr. Duncan himself cites several, and a very interesting one 
is mentioned by Leishman, in which delivery took place 295 days after 
a single coitus, the child weighing 12 lbs. 3 oz. 

It seems possible that, in some cases of protracted pregnancy, labor 
actually came on at the average time, but, on account of faulty posi- 
tions of the uterus or other obstructing cause, the pains were ineffective 
and ultimately died away, not recurring for a considerable time. 
Joulin relates some instances of this kind. In one of them the labor 
was expected from the 20th to the 25th of October. He was sum- 
moned on the 23d, and found the pains regular and active, but inef- 
fective ; after lasting the whole of the 24th and 25th they died away, 
and delivery did not take place until November 25th, after the lapse 
of a month. In this instance the apparent cause of difficulty was 
extreme anterior obliquity of the uterus. A precisely similar case 
came under my own observation. The lady ceased to menstruate on 
March 16, 1870. On December 12th, that is, on the 273d day, strong 
labor pains came on, the os dilated to the size of a florin, and the 
membranes became tense and prominent with each pain. After last- 
ing all night they gradually died away, and did not recur until 
January 12th, 304 days from the cessation of the last period. Here 
there Avas no assignable cause of obstruction, and the labor, when it 
did come on, was natural and easy. 

The curious fact that in both these cases, as in others of the same 
kind that are recorded, labor came on exactly a month after the 
previous ineffectual attempt at its establishment, affords, so far as it 
goes, an argument in favor of the view maintained by many that labor 
is apt to come on at what would have been a menstrual period. 

Signs of Recent Delivery. — From a forensic point of view it 
often becomes of importance to be able to give a reliable opinion as 
to the fact of delivery having occurred, and a few words may be here 
said as to the signs of recent delivery. Our opinion is only likely to 
be sought in cases in which the fact of delivery is denied, and in which 
we must, therefore, entirely rely on the results of a physical examina- 
tion. If this be undertaken within the first fortnight after labor, a 
positive conclusion can be readily arrived at. 

At this time the abdominal walls will still be found loose and flaccid, 
and bearing very evident marks of extreme distention in the cracks 
and fissures of the cutis vera. These remain permanent for the rest 
of the patient's life, and may be safely assumed to be signs of an 

1 Fecundity and Fertility, p. 348. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 173 

antecedent pregnancy, provided we can be certain that no other cause 
of extreme abdominal distention has existed, such as ascites or ovarian 
tumor. 

Within the first few days after delivery, the hard round ball formed 
by the contracted and empty uterus can easily be felt by abdominal 
palpation, and more certainly by combined external and internal ex- 
amination. The process of involution, however, by which the uterus 
is reduced to its normal size, is so rapid that after the first week it 
can no longer be made out above the brim of the pelvis. In cases in 
which an accurate diagnosis is of importance, the increased length of 
the uterus can be ascertained by the uterine sound, and its cavity will 
measure more than the normal two and a half inches for at least a 
month after delivery. It should not be forgotten that the uterine 
parietes are now undergoing fatty degeneration, and that they are 
more than usually soft and friable, so that the sound should be used 
with great caution, and only when a positive opinion is essential. The 
state of the cervix and of the vagina may afford useful information. 
Immediately after delivery the cervix hangs loose and patulous in the 
vagina, but it rapidly contracts, and the internal os is generally 
entirely closed after the eighth or tenth day. The remainder of the 
cervix is longer in returning to its normal shape and consistency. It 
is generally permanently altered after delivery, the external os remain- 
ing fissured and transverse, instead of circular with smooth margins, 
as in virgins. The vagina is at first lax, swollen, and dilated, but 
these signs rapidly disappear, and cannot be satisfactorily made out 
after the first few days. The absence of the fourchette may be recog- 
nized, and is a persistent sign. 

The presence of the lochia affords a valuable sign of recent delivery. 
For the first few days they are sanguineous, and contain numerous 
blood corpuscles, epithelial scales, and the debris of the decidua. 
After the fifth day they generally change in color, and become pale 
and greenish, and from the eighth or ninth day till about a month 
after delivery they have the appearance of thick opalescent mucus. 
They have, however, a peculiar, heavy, sickening odor, which should 
prevent their being mistaken for either menstruation or leucorrkoeal 
discharge. 

The appearance of the breasts will also aid the decision, for it is 
impossible for the patient to conceal the turgid, swollen condition of 
the mamma?, with the darkened areola?, and, above all, the presence 
of milk. If, on microscopic examination, the milk is found to contain 
colostrum corpuscles, the fact of very recent delivery is certain. In 
women who do not nurse it should be remembered that the secretion 
of milk often rapidly disappears, so that its absence cannot be taken 
as a sign that delivery has not taken place. On the whole, there 
should be no difficulty in deciding that a woman has been delivered, 
as some of the signs are persistent for the rest of her life ; but it is not 
so easy, unless we see the case within the first eight or ten days, to 
say how long it is since labor took place. 



174 



PREGNANCY 



CHAPTEE VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, 
SUPERFCETATION, EXTRA-UTERINE FCETATION, AND MISSED 
LABOR. 



The occurrence of more than one foetus in utero is far from un- 
common, but there are circumstances connected with it which justify 
the conclusion that plural births must not be classified as natural forms 
of pregnancy. The reasons for this statement have been well collected 
by Dr. Arthur Mitchell/ who conclusively shows that not only is 
there a direct increase of risk to the mother and her offspring, but 
that many abnormalities, such as idiocy, imbecility, and bodily de- 
formity, occur with much greater frequency in twins than in single- 
born children. He concludes that "the whole history of twin births 
is exceptional, indicates imperfect development and feeble organization 
in the product, and leads us to regard twinning in the human species 
as a departure from the physiological rule, and therefore injurious to 
all concerned." 

The frequency of multiple births varies considerably under dif- 
ferent circumstances. Taking the average of a large number of cases 
collected by authors in various countries, we find that twin pregnancies 
occur about once in 87 labors ; triplets once in 7679. A certain num- 
ber of quadruple pregnancies, and some cases of early abortion in 
which there were five foetuses, are recorded, so that there can be no 
doubt of the possibility of such occurrences ; but they are so extremely 
uncommon that they may be looked upon as rare exceptions, the 
relative frequency of which can hardly be determined. 

The frequency of multiple pregnancy varies remarkably in different 
races and countries. The following table 2 will show this at a glance : 



Relative Frequency of Multiple Pregnancies in 


Europe. 


Countries. 


Proportion of 

twin to single 

births. 


Proportion of 
tx-iplets. 


Proportion of 
quadruplets. 


England 


1 : 116 


1 : 6,720 




Austria 




94 






Grand Duchy of Baden .... 




89 


1 : 6,575 




Scotland 




95 






France 




99 


1 : 8,256 


1 : 2,074,306 


Ireland • 




64 


1 : 4,995 


1 : 167,226 


Mecklenburg-Schwerin 




68.9 


1 : 6,436 


1 : 183,236 


Norway .... 




81.62 


1 : 5,442 




Prussia 




89 


1 : 7,820 


1 : 394,690 


Russia 




50.05 


1 : 4,054 




Saxony 




79 


1 : 1,000 


1 : 400,000 


Switzerland 




102 






Wurtemberg 




862 


1 : 6,464 


1 : 110,991 



1 Med. Times and Gaz. , Nov. 1862. 

2 Puech : Des Naissances Multiples. 



ABNORMAL PREGNANCY. 175 

It will be seen that the largest proportion of multiple births occurs in 
Russia, and that the number of triple births is greatest where twin 
pregnancies are most frequent. Puech concludes that the number of 
multiple pregnancies is in direct proportion to the general fecundity 
of the inhabitants. 

Dr. Duncan has deduced some interesting laws, with regard to the 
production of twins, from a large number of statistical observations ; l 
especially that the tendency to the production of twins increases as the 
age of the woman advances, and is greater in each succeeding pregnancy, 
exception being made for the first pregnancy, in which it is greater than 
in any other. Xewly married women appear more likely to have twins 
the older they are. There can be no doubt that there is often a strong 
hereditary tendency in individual families to multiple births. A 
remarkable instance of this kind is recorded by Mr. Curgenven, 2 in 
which a woman had four twin pregnancies, her mother aud aunt each 
one, and her grandmother two. Simpson mentions a case of quadruplets, 
consisting of three males and one female, who all survived, the female 
subsequently giving birth to triplets. 3 

Sex of Children. — In the largest number of cases of twins the 
children are of opposite sexes, next most frequently there are two 
females, and twin males are the most uncommon. Thus, out of 
59,178 labors, Simpson calculates that twin male and female occurred 
once in 199 labors, twin females once in 226, and twin males once in 
258. The proportion of male to female births is also notably less in 
twin than in single pregnancies. 

Size of Foetuses. — Twins, and a fortiori triplets, are almost always 
smaller and less perfectly developed than single children. Hence the 
chances of their survival are much less, and Clarke calculates the 
mortality amongst twin children as one out of thirteen. Of triplets, 
indeed, it is comparatively rare that all survive ; while in quadruplets, 
premature labor and death of the foetuses are almost certain. It is a 
common observation that twins are often unequally developed at birth. 
By some this difference is attributed to the fact of their being of dif- 
ferent ages. It is probable, however, that in most of these cases the 
full development of one foetus has been interfered with by pressure of 
the other. This is far from uncommouly carried to the extent of de- 
stroying one of the twins, which is expelled at term, mummified and 
flattened between the living child and the uterine wall. In other 
cases, when one foetus dies it may be expelled without terminating the 
pregnancy, the other being retained in utero and born at term ; and 
those who disbelieve in the possibility of superfostation explain in this 
way the cases in which it is believed to have occurred. 

Multiple pregnancies depend on various causes. The most common 
is probably the simultaneous, or nearly simultaneous, maturation and 
rupture of two Graafian follicles, the ovules becoming impregnated at 
or about the same time. It by no means necessarily follows, even if 
more than one follicle should rupture at once, that both ovules should 

1 On Fecundity. Fertility, and Sterility, p. 99. 

2 Obst. Trans.. 1870. vol. xi. p. 106. 
s Obst. Works, p. 830 



176 PREGNANCY. 

be impregnated. This is proved by the occurrence of cases in which 
there are two corpora lutea with only one foetus. There are numerous 
facts to prove that ovules thrown off within a short time of each other 
may become separately impregnated, as in cases in which negro women 
have given birth to twins, one of which was pure negro, the other 
half-caste. 

It may happen, however, tnat a single Graafian follicle contains 
more than one ovule, as has actually been observed before its rupture ; 
or, as is not uncommon in the egg of the fowl, an ovule may contain a 
double germ, each of which may give rise to a separate foetus. 

Arrangement of the Fcetal Membranes and Placentae. — The 
various modes in which twins may originate explain satisfactorily the 
variations which are met with in the arrangement of the foetal mem- 
branes, and in the form and connections of the placentae. In a large 
proportion of cases there are two distinct bags of membranes, the 
septum between them being composed of four layers, viz., the chorion 
and amnion of each ovum. The placentae are also entirely separate. 
Here it is obvious that each twin is developed from a distinct ovum, 
having its own chorion and amnion. On arriving in the uterus it is 
probable that each ovum becomes fixed independently in the mucous 
membrane, and is surrounded by its own decidua reflexa. As growth 
advances the decidua reflexa generally atrophies from pressure, as it is 
not usual to find more than four layers of membrane in the septum 
separating the ova. In other cases there is only one chorion, within 
which are two distinct amnions, the septum then consisting of two 
layers only. Then the placentae are generally in close apposition, and 
become fused into a single mass ; the cords, separately attached to each 
foetus, not infrequently uniting shortly before reaching the placental 
mass, their vessels anastomosing freely. In other more rare instances 
both foetuses are contained in a common amniotic sac; but as the 
amnion is a purely foetal membrane, it is probable that, when this 
arrangement is met with, the originally existing septum between the 
amniotic sacs has been destroyed. In both these latter cases the twins 
must have been developed from a single ovule containing a double 
germ, and Schroeder states that they are then always of the same sex, 
and have a striking similarity to each other. Dr. Brunton 1 has 
started a precisely opposite theory, and has tried to prove that twins 
of the same sex are contained in separate bags of membrane, while 
twins of opposite sexes have a common sac. He says that, out of 
twenty-five cases coming under his observation, in fifteen the children 
contained in different sacs were of the same sex, but in the remaining 
ten, in which there was only one sac, they were of opposite sexes. It 
is difficult to believe that there is not an error in these observations, 
since twins contained in a single amniotic sac do not occur nearly as 
often as ten times out of twenty-five cases, and no distinction is made 
between a common chorion with two amnions and a single chorion 
and amnion. The facts of double monstrosity also disprove this 
view, since conjoined twins must of necessity arise from a single 

1 Obst. Trans., 1870, vol. xl. p. 67. 



ABNORMAL PREGNANCY. 177 

ovule with a double germ, and there is no instance on record in which 
they were of opposite sexes. 

In triplets the membranes and placenta? may be all separate, or, as 
is commonly the case, there is one complete bag of membranes, and a 
second having a common chorion, with a double amnion. It is prob- 
able, therefore, that triplets are generally developed from two ovules, 
one of which contains a double germ. 

Diagnosis of Multiple Pregnancy. — It is comparatively seldom 
that twin pregnancy can be diagnosed before the birth of the first 
child, and, even when suspicion has arisen, its indications are very 
defective. There is generally an unusual size and an irregularity of 
shape of the uterus, sometimes even a distinct depression or sulcus 
between the two foetuses. "When such a sulcus exists it may be possi- 
ble to make out parts of each foetus by palpation on either side of the 
uterus. The only sign, however, on which the least reliance can be 
placed is the detection of two foetal hearts. If two distinct pulsations 
are heard at different parts of the uterus ; if, on carrying the stetho- 
scope from one point to another, there is an interspace w T here pulsa- 
tions are no longer audible, or when they become feeble, and again 
increase in clearness as the second point is reached ; and, above all, if 
we are able to make out a difference in frequency between them, the 
diagnosis is tolerably safe. It must be remembered, however, that 
the sounds of a single heart may be heard over a larger space than 
usual, and hence a possible source of error. Twin pregnancy, moreover, 
may readily exist without the most careful auscultation enabling us to 
detect a double pulsation, especially if one child lie in the dorso- 
posterior position, when the body of the other may prevent the trans- 
mission of its heart's beat. The so-called placental souffle is generally 
too diffuse and irregular to be of any use in diagnosis, even when it is 
distinctly heard at separate parts of the uterus. 

Superfcetation and Superfecundation. — Closely connected with 
the subject of multiple pregnancies are the conditions known as super- 
fecundation and superfcetation, regarding which there have been much 
controversy and difference of opinion. 

By the former is meant the fecundation, at or near the same period 
of time, of two separate ovules before the decidua lining the uterus 
has been formed, which by many is supposed to form an insuperable 
obstacle to subsequent impregnation. The possibility of this occur- 
rence has been incontestably proved by the class of cases already 
referred to, in which the same woman lias given birth to twins bearing 
evident traces of being the offspring of fathers of different races. 

By superfcetation is meant the impregnation of a second ovule when 
the uterus already contains an ovum which has arrived at a consider- 
able degree of development. The cases which are supposed to prove 
the possibility of this occurrence are very numerous. They are those 
in which a woman is delivered simultaneously of foetuses of very dif- 
ferent ages, one bearing all the marks of having arrived at term, the 
other of prematurity ; or those in which a woman is delivered of an 
apparently mature child, and, after the lapse of a few months, of 
another equally mature. The possibility of superfcetation is strongly 
12 



178 PREGNANCY. 

denied by many practitioners of eminence, and explanations are given 
which doubtless seem to account satisfactorily for a large proportion 
of the supposed examples. In the former class of cases it is supposed, 
with much probability, that there is an ordinary twin pregnancy, the 
development of one foetus being retarded by the presence in utero of 
another. That this is not an uncommon occurrence is certain, and 
the fact has been already alluded to in treating of twin pregnancy. 
In cases of the latter kind it is possible that some of them may be 
due to separate impregnation in a bilobed uterus, the contents of one 
division being thrown off a considerable time before those of the other. 
Numerous authentic examples of this occurrence are recorded, but by 
far the most remarkable is that related by Dr. Ross, of Brighton, 
which has been already referred to (p. 70). In this case the patient 
had previously given birth to many children without any suspicion of 
her abnornal formation having arisen, and, had it not been detected 
by Dr. Ross, the case might fairly enough have been claimed as an 
indubitable example of superfoetation. 

Making every allowance for these explanations, there remains a 
considerable number of cases which it is very difficult to account for, 
except on the supposition that the second child has been conceived a 
considerable time after the first. Those interested in the subject w T ill 
find a large number of examples collected in a valuable paper by Dr. 
Bonnar, of Cupar. 1 He has adopted the ingenious plan of consulting 
the records of the British peerage, where the exact date of the birth of 
successive children of peers is given, without, of course, any reasonable 
possibility of error, and he has collected numerous examples of births 
rapidly succeeding each other which are apparently inexplicable on 
any other theory. In one case he cites, a child was born September 
12, 1849, and the mother gave birth to another on January 24, 1850, 
after an interval of only 127 days. Subtracting from that 14 days, 
which Dr. Bonnar assumes to be the earliest possible period at which 
a fresh impregnation can occur after delivery, we reduce the gestation 
to 113 days — that is, to less than four calendar months. As both 
these children survived, the second child could not possibly have been 
the result of a fresh impregnation after the birth of the first ; nor could 
the first child have been a twin prematurely delivered ; for, if so, it 
must have only reached rather more than the fifth month, at which 
time its survival would have been impossible. 

Besides the numerous examples of cases of this kind recorded in 
most obstetric works, there are one or two of miscarriage in the early 
months, in which, in addition to a foetus of four or five months' growth, 
a perfectly fresh ovum of not more than a month's development w r as 
thrown off. One such case was shown at the Obstetrical Society in 
1862, which was reported on by Drs. Harley and Tanner, who stated 
that in their opinion it was an example of superfoetation. A still more 
conclusive case is recorded by Tyler Smith. 2 "A young married woman, 
pregnant for the first time, miscarried at the end of the fifth month, 
and some hours afterward a small clot was discharged, enclosing a 

1 Edin. Med. Journ., 1864-65. 2 Manual of Obstetrics, p. 112. 



ABNORMAL PREGNANCY. 



179 



perfectly healthy ovum of about oue month. There were no signs of 
a double uterus in this case. The patient had menstruated regularly 
during the time she had been pregnant." This case is of special inter- 
est from the fact of the patient having menstruated during pregnancy 
— a circumstance only explicable on the same anatomical grounds 
which render superfoetation possible. So far as I know, it is the only 
instance in which the coincidence of superfoetation and menstruation 
during early pregnancy has been observed. 

The objections to the possibility of superfoetation are based on the 
assumptions that the decidua so completely fills up the uterine cavity 
that the passage of the spermatozoa is impossible ; that their passage 
is prevented by the mucous plug which blocks up the cervix ; and 



Fig. 7 




Illustrating the cavity between the decidua vera and the decidua reflexa during the early 
months of pregnancy. (After Coste.) 



that when impregnation has taken place ovulation is suspended. It 
is, however, certain that none of these is an insuperable obstacle to a 
secoud impregnation. The first was originally based on the older and 
erroneous view which considered the decidua to be an exudation lining 
the entire uterine cavity, and sealing up the mouths of the Fallopian 
tubes and the aperture of the internal os uteri. The decidua reflexa, 
however, does not come into apposition with the decidua vera until 
about the eighth week of pregnancy, and, therefore, until that time 
there is a free space between the two membranes through which the 
spermatozoa might pass to the open mouths of the Fallopian tube, and 
in which a newly impregnated ovule might graft itself. A reference 
to the accompanying figure of a pregnancy in the third month, copied 
from Coste's work, will readily show that, as far as the decidua is con- 



180 PREGNANCY. 

cerned, there is no mechanical obstacle to the descent and lodgment of 
another impregnated ovule (Fig. 78). Then, as regards the ping of 
mucus, it is pretty certain that this is in no way different from the 
mucus filling the cervix in the non-pregnant state, which offers no 
obstacle at all to the passage of the spermatozoa. Lastly, respecting 
the cessation of ovulation during pregnancy, this, no doubt, is the 
rule, and probably satisfactorily explains the rarity of superfoetation. 
There are, however, a sufficient number of authenticated cases of men- 
struation during pregnancy, to prove that ovulation is not always 
absolutely in abeyance ; and, as long as it occurs, there is unquestion- 
ably no positive mechanical obstruction, at least in the early months 
of pregnancy, in the way of the impregnation and lodgment of the 
ovules that are thrown off. The reasonable conclusion, therefore, 
seems to be that, although a large majority of the supposed cases are 
explicable in other ways, it cannot be admitted that superfoetation is 
either physiologically or mechanically impossible. 

Extra-uterine Pregnancy. — The most important of the abnormal 
varieties of pregnancy, if we consider the serious and very generally 
fatal results attending it, is the so-called extra-uterine gestation, or 
ectopic pregnancy, as some prefer to call it, in which the impregnated 
ovum is arrested, and more or less developed outside the uterine cavity. 

Until comparatively recently it has been divided into three chief 
classes — tubal, abdominal, and ovarian — according to the position in 
which the fecundated ovum was supposed to be developed. This di- 
vision was based on the comparatively limited pathological investigation 
of cases which had then been made. Within the past few years very 
great attention has been paid to the subject, and our most experienced 
abdominal surgeons and pathologists are now of opinion that all extra- 
uterine pregnancies are primarily tubal, the other supposed varieties 
being subsequent developments after the escape of the ovum from its 
original site by rupture or otherwise. This is the view strongly main- 
tained by Lawson Tait, 1 who has an unrivalled operative experience of 
these cases, and also by Bland Suttou, 2 who lays down the rule that 
u all forms of extra-uterine gestation pass their primary stages in the 
Fallopian tube." The whole tendency of modern opinion is to sup- 
port this view. 

Classification. — It is necessary, however, to state the classifications 
which have been given in obstetric works, and to explain their relation 
to the more modern theory, the more so as there are many authorities 
of eminence who still adhere to the older views. The following classes 
have been generally admitted : 1st, and most common of all, tubal 
gestation, and as varieties of this, although by some made into distinct 
classes, (a) interstitial, (b) tubo-ovarian or ampullar gestation, and (c) 
sub-peritoneo -pelvic, or intra-ligamentous. In the first of these sub- 
divisions the ovum is arrested in the part of the Fallopian tube that is 
situated in the substance of the uterine parietes ; in the second, at or 
near the fimbriated extremity of the tube — so that part of its cyst is 
formed by the tube and part by the ovary ;• in the third, an originally 

1 Lectures on Ectopic Pregnancy, 1888. 

2 Surgical Diseases of the Ovaries and Fallopian, Tubes, 1891. 



ABNORMAL PREGNANCY. 181 

tubal pregnancy develops into the broad ligament, and continues this 
development beneath the peritoneum of the pelvic floor. 2d. Abdomi- 
nal gestation, in which an impregnated ovum, instead of finding its way 
into the tube, falls into the peritoneal cavity, and there becomes attached 
aud developed ; this is the so-called " primary " abdominal pregnancy, 
the possibility of which is denied by almost all recent writers, and of 
which no undoubted example has ever been proved to exist ; or the so- 
called " secondary" abdominal gestation, in which au extra-uterine 
pregnancy, originally tubal, becomes ventral, through rupture aud 
escape of its contents into the abdominal cavity ; or in which an intra- 
ligamentous pregnancy continues to develop until it lifts up the ab- 
dominal peritoneum, and forms a purely extra-peritoneal variety of 
abdominal gestation. This has been called by Hart and Carter sub- 
peritoneo-abdominal. 1 3d. Ovarian gestation, the existence of which 
was always denied by many writers of eminence, such as Velpau and 
Arthur Farre, while it is maintained by others of equal celebrity, such 
as Kiwisch, Coste, and Hecker. It must be admitted that it is ex- 
tremely difficult to understand how au ovarian pregnancy, in the strict 
sense of the word, could occur, for it implies that the ovule has become 
impreguanted before the laceration of the Graafiau follicle, through the 
coats of which the spermatozoa must have passed. Coste, indeed, be- 
lieved that this frequently happened; but, while spermatozoa have 
been detected on the surface of the ovary, their penetration into the 
Graafian follicle has never been demonstrated. Farre also clearly 
showed that in most cases of supposed ovarian pregnancy the surround- 
ing structures were so altered that it was impossible to trace their exact 
origin and to say to a certainty that the foetus was really within the 
substance of the ovary. Kiwisch suggested an explanation of these 
cases by supposing that sometimes the Graafian follicle may rupture, 
and that the ovule may remain within it without being discharged. 
Through the rent in the walls of the follicle the spermatozoa may reach 
and impregnate the ovule, which may develop in the situation in which 
it has been detained. The subject has been ably considered by Puech, 2 
who admits two varieties of ovarian pregnancy, according as the foetus 
has developed in a vesicle which has remained open, or in one which 
has closed immediately after fecundation. He considers that most 
cases of so-called ovarian pregnancy are either dermoid cysts, ovario- 
tubal pregnancies, or abdominal pregnancies in which the placenta is 
attached to the ovary, and that even in the rare cases of true ovarian 
pregnancy the progress and results do not differ from those of abdomi- 
nal pregnancy. Doran 3 has submitted all the published cases of sup- 
posed ovarian pregnancy to a critical analysis, and has come to the 
conclusion that in no single instance are they authentic. As no one 
has ever seen a case in which the impregnated ovum is lying within the 
substance of the ovary, the occurrence of this form of ectopic gestation 
must be taken as altogether hypothetical. 4th. There is a rare condi- 
tion in which an ovum is developed in the supplementary horn of a 

1 " Sectional Anatomy of Advanced Extra-uterine Gestation," Edin. Med. Journ., October, 1887. 

2 Annal. de Gynec, 1878, torn. x. p. 10_\ 
• Obstet. Trans, vol. xxxv., p. 237. 



182 PREGNANCY. 

bi-lobed uterus. This is, strictly speaking, a pregnancy in an abnormal 
uterus, rather than an ectopic gestation ; but, clinically speaking, since 
it leads to similar results, it may be considered with it. 

For the sake of clearness, we may place these varieties of extra- 
uterine gestation in the following tabular form, those in italics being 
considered by most modern authorities not to exist : 

a. Isthmial. 
f 1st. Tubal i b Tubo-ovarian, or ampullar. 
! [ c. Interstitial, or tubo-uterine. 

Primary . . . . \ 2d\ Abdominal. 
3d. Ovarian. 
I 4th. In bi-lobed uterus. 

Secondary, after f a - Sub-peritineo-pelvic, sometimes leading to 
rupture of -! sub-peritineo-abdominal. 

primary [ b - Abdominal. 

Causes. — The etiology of extra-uterine fcetation in any individual 
case must necessarily be almost always obscure. Broadly speaking, it 
may be said that extra-uterine fcetation may be produced by any con- 
dition which prevents or renders difficult the passage of the ovule to 
the uterus while it does not prevent the access of the spermatozoa to 
the ovule. Thus inflammatory thickening of the coats of the Fallopian 
tubes, by lessening their calibre, but not sufficiently so as to prevent 
the passage of the spermatozoa, may interfere with the movements 
of the tube which propel the ovum forward, and. so cause its arrest. 
Various morbid conditions, such as inflammatory adhesions, from old- 
standing peritonitis, pressing on the tube ; obstruction of its calibre 
by inspissated mucus or small polypoid growths ; the pressure of 
uterine or other tumors, and the like, are supposed to have a similar 
effect. Tait 1 believes that the most important cause is chronic sal- 
pingitis, leading to destruction of the epithelium lining the tubes. 
The function of the epithelial cilia being to favor the progress of the 
ovum toward the uterus, when they no longer exist the mucous lining 
of the tubes is reduced to a condition similar to that of the endo- 
metrium, and the ovum is apt to be arrested in transitu. Bland 
Sutton 2 admits this to be a possible although as yet an unproved 
explanation, and believes that a healthy Fallopian tube is as liable to 
become gravid as one that has been inflamed. The fact that extra- 
uterine pregnancies occur most frequently in multipara?, and compara- 
tively rarely in women under thirty years of age, tends to show that 
these conditions, which are clearly more likely to be met with in such 
women than in young primiparse, have considerable influence in their 
causation. A curiously large proportion of cases occur in women who 
have either been previously altogether sterile, or in whom a long in- 
terval of time has elapsed since their last pregnancy. The disturbing 
effects of fright, either during coition or a few days afterward, have 
been insisted on by many authors as a possible cause. Numerous cases 
of this kind are recorded; and, although the influence of emotion in 
the production of this condition is not susceptible of proof, it is not 

1 Op. cit., p. 4. 2 op. cit.. p. 309. 



ABNORMAL PREGNANCY. 183 

difficult to imagine that spasms of the Fallopian tubes might be pro- 
duced in this way, which would either interfere with the passage of the 
ovum, or direct it into the abdominal cavity. 

Several curious cases are recorded, which have given rise to a 
good deal of discussion, in which a tubal pregnancy existed while the 
corpus luteum was on the opposite side (Fig. 79). The most probable 

Fig. 79. 




Tubal pregnancy, with the corpus luteum in the ovary of the opposite side. The decidua is 
represented in the process of detachment from the uterine cavity. 

explanation, however, is that the fimbriated extremity of the tube in 
which the ovum was found had twisted across the abdominal cavity 
and grasped the opposite ovary, in this way, perhaps, producing a 
flexion which impeded the progress of the ovum it had received into 
its canal. Tyler Smith suggested that such cases might be explained 
by supposing that the ovum, after reaching the uterus, failed to graft 
itself in the mucous membrane, but found its way into the opposite 
Fallopian tube. Kussmaul ' thinks that such a passage of the ovum 
across the uterine cavity may be caused by muscular contraction of 
the uterus, occurring shortly after conception, squeezing the yet free 
ovum upward toward the opening of the opposite tube, and possibly 
into the tube itself. 

The history and progress of cases of extra-uterine pregnancy are 
materially different according to their site, and it is, therefore, neces- 
sary to examine its varieties in detail. 

Tubal Pregnancies. — When the ovum is arrested in any part of 
the Fallopian tube the chorion soon commences to develop villi, just 
as in ordinarv pregnancy, which engraft themselves into the mucous 
liuing of the tube, and fix the ovum in its new position. The mucous 
membrane becomes hypertrophied, much in the same way as that of the 
uterus under similar circumstances, so that it becomes developed into 
a sort of pseudo-decidua, the uterine extremity of which has been 
observed to be open and in communication with the lining membrane 
of the uterus. 2 Inasmuch, however, as the mucous coat of the tubes 

i Mon. f. Geburt., 1862, Bd. xx. S. 295. 

2L. Bandl : Billroth's Handbuch der Frauenkrankheiten. 



184 



PREGNANCY 



Fig. 80. 



is not furnished with tubular glands, a true decidua can scarcely be 
said to exist; nor is there any growth of membrane around the ovum 

analogous to the decidua reflexa. The 
ovum is, therefore, comparatively 
speaking, loosely attached to its ab- 
normal situation, and hence hemor- 
rhage from laceration of the chorion 
villi can very readily take place. 
This leads to extravasation of blood 
between the villi, and it is often the 
determining cause of rupture, in con- 
sequence of the sudden increase in 
size of the tube contents. Should 
rupture not occur the ovum may be 
transformed into a fleshy mole, anal- 
ogous to the uterine mole. And this 
is, doubtless, the origin of many 
cases of the so-called " hsemato-salpinx." The dependence of this on 
pregnancy may generally be proved by the tube contents showing 
chorionic villi on microscopical examination (Fig. 80). 




Microscopical appearances of chorionic 
villi in transverse section from a tubal mole 
—low magnification. (After Bland Sutton.) 



Fig. 81. 




Tubal pregnancy. (From a specimen in the Museum of King's College.) 



Tubal Abortion. — In cases in which the distal extremity of the 
tube is not occluded the mole may be extruded through it into the 
peritoneal cavity. This occurrence has received the name of tubal 
abortion. This can only happen in the early period of tubal preg- 
nancy, before the second month, when the ovum is very small, and 
when the ostium is still unclosed. It is discharged into the perito- 
neum, accompanied by many blood-clots. It may happen that the ovum 



ABNORMAL PREGNANCY. 185 

is not completely expelled, part being still attached to the distal ex- 
tremity of the tube, and this may give rise to repeated hemorrhages. 
In this way are explained many of the cases of hematocele, formerly 
referred to other causes, such as the reflux of blood through the tubes 
during menstruation. 

It is seldom that any development of the chorion villi into distinct 
placental structure is observed ; this is probably owing to the fact that 
laceration and death generally occur before the period at which the 
placenta is normally formed. The muscular coat of the tube soon 
becomes hypertrophied, and as the size of the ovum increases the fibres 
are separated from each other, so that the ovum protrudes at certain 
points through them, and at these it is only covered by the stretched 
and attenuated mucous and peritoneal coats of the tube. At this time 
the tubal pregnancy forms a smooth oval tumor, which, as a rule, has 
not formed any adhesions to the surrounding structures (Fig. 81). 
The part of the tube unoccupied by the ovum may be found unaltered, 
and permeable in both directions ; or, more frequently, it becomes so 
stretched and altered that its canal cannot be detected. Most fre- 
quently it is that part of the tube nearest the uterus which cannot be 
made out. Sutton states that by the eighth week the abdominal ex- 
tremity of the tube generally becomes obliterated by the protrusion of 
a ring of peritoneum around it, which gradually becomes occluded, and 
so hermetically closes the opening. When this occurs the gravid tube 
almost invariably bursts. 

Condition of the Uterus. — The condition of the uterus in this, 
as in other forms of extra-uterine pregnancy, has been the subject of 
considerable discussion. It is now universally admitted that the uterus 
undergoes a certain amount of sympathetic engorgement, the cervix 
becomes softened, as in natural pregnancy, and the mucous membrane 
develops into a true decidua. In many cases the decidua is found on 
post-mortem examination, in others it is not ; and hence the doubts 
that some have expressed as to its existence. The most reasonable 
explanation of its absence is that given by Duguet, 1 who has shown 
that it is far from uncommon for the uterine decidua to be thrown off 
en masse during the hemorrhagic discharges which so frequently pre- 
cede the fatal issue of extra-uterine gestation. 

Interstitial and False Ovarian Pregnancy. — When the ovum is 
arrested in that portion of the tube passing through the uterus, in 
so-called interstitial pregnancy (Fig. 82) the muscular fibres of the 
uterus become stretched and distended, and form the outer covering 
of the ovum. In this case rupture is delayed to a later date than in 
tubal pregnancy, but, when it occurs, hemorrhage is greater, in con- 
sequence of the thickness of the gestation sac, and the fatal issue is 
more certain and rapid. When, on the other hand, the site of arrest 
is in the fimbriated extremity of the tube, the containing cyst is formed 
partly of the fimbria of the tube, partly of ovarian tissue ; hence it 
is much more distensible, and the pregnancy may continue without 
laceration to a more advanced period, or even to term, so that when 

1 Annales de Gynecologie, 1874, torn. i. p. 269. 



186 



PREGNANCY. 



the ovum is placed in this situation the case much more nearly resem- 
bles one of abdominal pregnancy. 



Fig. 82. 




Interstitial or tubo-uterine pregnancy. (Guy's Hospital Museum. After Bland Suttox.) 

Progress and Termination. — The termination of tubal pregnancy, 
in most cases, is death, produced by laceration giving rise either to in- 
ternal hemorrhage or to subsequent intense peritonitis. Rupture usually 
occurs at an early period of pregnancy, most generally from the fourth 
to the twelfth week, rarely later. However, a few instances are re- 
corded in which it did not take place until the fourth or fifth month, 
and Saxtorph and Spiegelberg have recorded apparently authentic cases 
in which the pregnancy advanced to term without laceration ; these 
were, however, probably examples of the sub-peritoneo-pelvic or sec- 
ondary abdominal varieties. It is generally effected by distention of 
the tube, which at last yields at the point which is most stretched ; 
and sometimes it seems to be hastened or determined by accidental cir- 
cumstances, such as a blow, a fall, or the excitement of sexual inter- 
course. 

Symptoms of Rupture. — The symptoms accompanying rupture 
are those of intense collapse, often associated with severe abdominal 
pain, produced by the laceration of the cyst. The patient will be 
found deadly pale, with a small, thready, and almost imperceptible 
pulse, perhaps vomiting, but with mental faculties clear. If the 
hemorrhage be considerable, she may die without any attempt at 
reaction. Sometimes, however — and this generally occurs in cases in 



ABNORMAL PREGNANCY, 



187 



which the tube tears, the ovura remaining intact — the hemorrhage 
may cease on account of the ovum protruding through the aperture 
and acting as a plug. The patient may then imperfectly rally, to be 
again prostrated by a second escape of blood, which proves fatal. If 
the los3 of blood is not of itself sufficient to cause death from shock 
and anaemia, the fatal issue is generally only postponed, for the effused 
blood soon sets up a violent general peritonitis, which rapidly carries 
off the patient. This is the general course of events in the most 
common cla^s of cases, in which the rupture involves the peritoneal 
surface of the tube. The hemorrhage then takes place directly into 
the peritoneal cavity, and, unless laparotomy is performed, is most usu- 
ally fatal. 



Fig. 83. 




Extra-uterine preguancy at term of the secondary abdominal variety. (After a case of 
Dr. A. Sibley Campbell's.) 



In the minority of cases of rupture, the proportion being given by 
Sutton as 1 to 3, the laceration takes place in that part of the tube 
which is not covered with peritoneum, that is, the under surface of 
the middle third of the tube. The blood then escapes into the con- 
nective tissue of the broad ligament, and is consequently extra- 
peritoneal. The space into which the blood can pour is much more 
limited than in the former case, and the results are less uniformly 
disastrous. If the ovum and the patient both survive the immediate 



188 PREGNANCY. 



rupture, the former continues to grow, and the case is transformed into 
one of sub-peritoneo-pelvic gestation. The case is then subjected to 
the rules of treatment presently to be discussed when considering 
secondary abdominal pregnancy. (Fig. 83.) 

Diagnosis. — The possibility of diagnosing tubal gestation before 
rupture occurs is a question of great and increasing interest, from the 
fact that, could its existence be ascertained, we might very fairly hope 
to avert the almost certainly fatal issue which is awaiting the patient. 
Unfortunately, the symptoms of tubal pregnancy are always obscure, 
and too often death occurs without the slightest suspicion as to the 
nature of the case having arisen. In the first place it is to be observed 
that all the usual sympathetic disturbances of pregnancy exist: the 
breasts enlarge, the areola? darken, and morning sickness is present. 
There is also an arrest of menstruation ; but, after the absence of one 
or more periods, there is often an irregular hemorrhagic discharge. 
This is an important symptom, the value of which in indicating the 
existence of tubal pregnancy has of late years been much dwelt upon 
by various authors, both in this country and abroad. It may probably 
be attributed to partial detachment of the chorion villi, produced by 
the ovum growing out of proportion to the tube in which it is con- 
tained. Whether this is the correct explanation or not, it is a fact 
that irregular hemorrhage very generally precedes the laceration for 
several days or more. Associated with the hemorrhage there may 
occasionally be found shreds of the decidual lining of the uterus, the 
presence of which would materially aid the diagnosis. Accompanying 
this hemorrhage there is almost always more or less abdominal pain, 
produced by the stretching of the tissues in which the ovum is placed, 
and this is sometimes described as being of very intense and crampy 
character. If, then, we meet with a case in which the symptoms of 
early pregnancy exist, in which there are irregular losses of blood, 
possibly discharge of membranous shreds, and abdominal pain, a care- 
ful examination should be insisted on, and then the true nature of the 
case may possibly be ascertained. Should extra-uterine foetation exist, 
we should expect to find the uterus somewhat enlarged, and the cervix 
softened, as in early pregnancy, but both these changes are doubtless 
generally less marked than in normal pregnancy. This fact of itself, 
however, is of little diagnostic value, for slight differences of this kind 
must always be too indefinite to justify a positive opinion. 

The existence of a peri-uterine tumor, rounded or oval in outline, 
and producing more or less displacement of the uterus, in the direction 
opposite to that in which the tumor is situated, may point to the exist- 
ence of tubular foetation. By bimanual examination, one hand de- 
pressing the abdominal wall, while the examining finger of the other 
acts in concert with it either through the vagina or rectum, the size 
and relations of the growth may be made out. There are various 
conditions which give rise to very similar physical signs, such as small 
ovarian or fibroid growths, or the effusion of blood around the uterus ; 
and the differential diagnosis must always be very difficult and often 
impossible. A curious example of the difficulty of diagnosis is re- 
corded by Joulin, in which Huguier and six or seven of the most 



ABNORMAL PREGNANCY. 189 

skilled obstetricians of Paris agreed on the existence of extra-uterine 
pregnancy, and had, in consultation, sanctioned an operation, when 
the case terminated by abortion, and proved to be a natural pregnancy. 
The use of the uterine sound, which might aid in clearing up the case, 
is necessarily contra-indicated unless uterine gestation is certainly dis- 
proved. Hence it must be admitted that positive diagnosis must 
always be very difficult. So that the most we can say is, that when 
the general signs of early pregnancy are present, associated with the 
other symptoms and signs alluded to, the suspicion of tubal preg- 
nancy may be sufficiently strong to justify us in taking such action as 
may possibly spare the patient the necessarily fatal consequence of 
rupture. 

Treatment. — If the diagnosis were quite certain, the removal of the 
entire Fallopian tube and its coutents by abdominal section would be im- 
peratively called for, aud would neither be more difficult uor more danger 
ous than ovariotomy; for, at this stage of extra-uterine fcetation, there 
are no adhesions to complicate the operation. This operation has been 
performed in many cases with a most happy result, and there can be 
no doubt that in the hands of an operator sufficiently expert in abdom- 
inal surgery, it is the proper course to adopt, whenever the symptoms 
are sufficiently well marked to indicate its necessity. 

It is to be observed, however, that the uncertainty in the diagnosis 
in cases of this kind is very great, and it requires a good deal of ex- 
perience and self-reliance to enable the practitioner to adopt so radical 
a procedure. It is not surprising, therefore, that many expedients 
have been suggested and tried for arresting the growth of the ovum, 
and thus leaving it quiescent in the tube. Many cases have been 
recorded in which the issue has been supposed to be satisfactory. 
Whether they were so in fact, or whether the diagnosis was erroneous, 
as the opponents of such procedures are so apt to suggest, cannot, of 
course, be proved in the nature of things. Such procedures are char- 
acterized by Tait as "mere nonsense, ' n and by Sutton as so unsatis- 
factory as not to merit discussion. It must be fully admitted that 
laparotomy in competent hands is infinitely more satisfactory, and it 
may be confidently recommended in every case in which the diagnosis 
is sufficiently plain. There will always, however, be a certain number 
of cases in which, either from the surroundings, the want of assistance 
or instruments, or of sufficient surgical aptitude on the part of the 
medical attendant, such radical measures cannot be adopted, and, there- 
fore, the methods referred to seem worthy of consideration. 

Dr. Thomas, of Xew York, 2 has recorded a most instructive case, in 
which he saved the life of the patient by a bold operation. The nature 
of the case was rendered pretty evident by the signs above described, 
and Thomas opened the cyst from the vagina by a platinum knife, 
rendered incandescent by a galvanic battery, by which means he hoped 
to prevent hemorrhage. Through the opening thus made he removed 
the foetus. In subsequently attempting to remove the placenta very 
violent hemorrhage took J)lace, which was only arrested by injecting 

i Op. cit., p. 53. 

2 New York Med. Journ., 1875, vol. xxi. p. 561. 



190 PREGNANCY. 

the cyst with a solution of persulphate of irou. The remains of the 
placenta subsequently came away piecemeal, after an attack of septi- 
cemia, which was kept within bounds by freely washing out the cyst with 
an antiseptic lotion, the patieut eventually recovering. Should this 
operation be resorted to, it would be better not to remove the placenta, 
but to plug the gestation sac with antiseptic gauze, frequently changed, 
and trust to antiseptic injections and thorough drainage to prevent 
septic mischief. This procedure has not, so far as I know, been again 
adopted ; the operation seems as severe and difficult as laparotomy, 
which would be, in every way, preferable. 

Means of Destroying 1 the Vitality of the Foetus. — Another 
mode of managing these cases is to destroy the foetus, so as to check 
its further growth, in the hope that it may remain inert and passive 
within its sac. Various operations have been suggested and practised 
for this purpose. Thus needles have been introduced into the tumor, 
through which currents of electricity have been passed, either the con- 
tinuous current, or, as has been suggested by Duchenne, a spark of 
franklinic electricity. Hicks and others have endeavored to destroy 
the foetus by passing an electro-magnetic current through it by means 
of a needle. Of late years a large number of carefully recorded cases 
have been published, chiefly in America, in which the faradic current 
has been used, apparently with perfect success, one pole being passed 
through the rectum or vagina to the side of the ovum, the other being 
placed on a point in the abdominal wall two or three inches above 
Poupart's ligament; or Apostolus vaginal electrode, in which both 
poles are combined, might be used. The number of cases is so con- 
siderable 1 that it is quite futile to talk of this plan as "mere non- 
sense/' or unworthy of consideration. It cannot be compared with 
laparotomy, uuder the conditions already mentioned, but when lapar- 
otomy from any cause is not feasible, it appears to offer a hopeful re- 
source. The current should be passed daily for at least ten minutes, 
and continued for a week or two until the shrinking of the tumor gives 
satisfactory evidence of the death of the foetus. This practice is per- 
fectly safe, and there can be no rational objection to its being tried. 
Aveling makes the reasonable suggestion that the current acts by pro- 
ducing " tetanic contractions of the foetal heart due to the repeatedly 
broken current of an induction machine." 2 Simple puncture of 
the cyst has been successfully practised on several occasions, either 
with a small trocar and canula, or with a simple needle. A very 
interesting case, in which the development of a two months' tubal 
gestation was arrested in this way, is recorded by Greenhalgh, 3 and 
another by the late Professor Martin, of Berlin. 4 Joulin suggested 
that not only should the cyst be punctured, but that a solution of 
morphia should be injected into it, which, by its toxic influence, 
would insure the destruction of the foetus; and this is probably one 
of the best means at our disposal for destroying the foetus. Friedreich 
and others have reported successful cases, one-fifth of a grain of mor- 

1 See various papers in the Trans, of the Araer. Gyn. Soc. ; also Lusk's Midwifery, 1892. 

2 " The Diagnosis and Electrical Treatment of Early Extra-uterine Gestation," Brit. Gyn. Journ., 
1888-89, vol iv. p. 24. 

s Lancet, 1867. 4 Monat. f. Gehurt., 1868, Bd, xxxii. S. 140. 



ABNORMAL PREGNANCY. 191 

phia being injected into the sac every second day, until it had obviously 
begun to shrink. 

Other means proposed for effecting the same object, such as pressure, 
or the administration of toxic remedies by the mouth, are far too un- 
certain to be relied on. The simplest and most effectual plan would 
be to introduce the needle of an aspirator, by which the liquor amnii 
would be drawn off, and the further growth of the foetus effectually 
prevented. Parry, 1 indeed, is opposed to this practice, and has col- 
lected several cases in which the puncture of the cyst was followed by 
fatal results, either from hemorrhage or septicaemia. In these, how- 
ever, an ordinary trocar and canula were probably employed, which 
would necessarily admit air into the sac. It is difficult to imagine 
that a fine hair-like aspirating needle, rendered perfectly aseptic, could 
have any injurious results ; and it could do no harm, even if an error 
of diagnosis had been made, and the suspected extra-uterine fcetation 
turned out to be some other sort of growth. 

Treatment when Rupture has Occurred. — AVhen the chance of 
arresting the growth of a tubular fcetation has never arisen, and Ave 
first recognize its existence after laceration has occurred, and the patient 
is collapsed from hemorrhage, what course are we to pursue? Hitherto 
all that has generally been clone is to attempt to rally the patient by 
stimulants, and, in the unlikely event of her surviving the immediate 
effects of laceration, endeavoring to control the subsequent peritonitis, 
in the hope that the effused blood may become absorbed, as in pelvic 
hematocele. This is, indeed, a frail reed to rest upon, and when lacera- 
tion of a tubal gestation, advanced beyond a month, has occurred, 
death has been the almost certain result. It is now universally ad- 
mitted that in such cases practically the only hope for the patient lies 
in the immediate performance of laparotomy, the rapid clearing away 
of the effused blood, and the search for, and ligature of, the ruptured 
tube. Mr. Lawson Tait's brilliant record of 42 cases, 39 of which 
recovered, would alone prove this to be, beyond any question, the 
proper, and indeed the only possible, practice, and happily many others 
are now able to record similar results. In these cases, in which rup- 
ture is never delayed beyond the twelfth or thirteenth week of gesta- 
tion, there are rarely any adhesions, and the operation presents no 
particular difficulty. As a rule, death does not follow rupture for 
some hours, so that there would be usually time for the operation, and 
the extreme prostration might be, perhaps, temporarily counteracted 
by saline transfusion. Pressure on the abdominal aorta, resorted to 
when the patient is first seen, and saline injections into the rectum, 
might possibly be employed with advantage to check further hemor- 
rhage, until the question of operation is decided. We must remember 
that the alternative is death, and hence any operation which would 
afford the slightest hope of success would be perfectly justifiable. 

In the second class of cases, in w T hich the rupture is extra-peritoneal, 
the necessity for immediate operation is not so urgent. Cases of this 
kind are not so intense in their character, and they rally much more 

1 Parry on Extra-uterine Pregnancy, p. 204. 



192 



PREGNANCY 



completely ; if they do so, it will be best not to interfere until a later 
date. 

Howard Kelly 1 contends that in cases of this kind, when intra-liga- 
mentous rupture has occurred, and the patient is sufficiently rallied, 
the best plan is to open the gestation sac from the vagina, to clear out 
its contents, plug the cavity with iodoform gauze, which is kept in situ 
for three or four days, and subsequently wash it out with autiseptic 
lotions. The sac being entirely extra-peritoneal, there is no risk of 
septic infection of the peritoneal cavity, and the drainage is thorough. 
Kelly reports thirteen cases which he had treated successfully in this 
way. Gynecologists are tending more and more to the use of the 
vaginal route in operations about the pelvis, and this procedure is cer- 
tainly a promising one. This method is not suitable for (a) an unrup- 
tured tube, (6) one which ruptured quite recently, or (c) an advanced 
extra-uterine pregnancy. 

Secondary Abdominal Pregnancy. — In the second of the two 
classes into which, for practical convenience, we have divided extra- 
uterine gestation, the ovum is developed in the abdominal cavity. It is, 
as we have seen, now generally admitted that there is no such a condition 
as primary abdominal pregnancy. Practically we may consider all the 
cases in which the foetus has developed in the abdominal cavity to have 
been primarily tubal or interstitial. Either the tube has burst into the 
peritoneum at a very early period of pregnancy, and the ovum has 
maintained its vitality, or, more commonly, there has been an extra- 
peritoneal rupture, and subsequently the gestation sac has again given 
way, and the foetus has found its way into the abdominal cavity. 

Fig. 87. 




Uterus and foetus in a case of abdominal pregnancy. 

Formation of a Cyst around the Ovum. — In the large majority 
of cases the ovum produces considerable irritation, resulting in the 
exudation of plastic material, which is thrown around it, so as to form 



Amer. Gyn. Trans., 1896, vol. xxi. p. 180. 



ABNORMAL PREGNANCY. 193 

a secondary cyst or capsule, in which maternal vessels are largely 
developed, and which stretches, pari passu, with the growth of the 
ovum (Fig. 84). This may be partly composed of remnants of rup- 
tured tube, and of the layers of the broad ligament, and to its external 
surface portions of intestine and omentum are frequently adherent. 
The placenta may be variously attached ; sometimes above the foetus 
at the upper part of the sac, sometimes below it, or partially to some 
of the adjacent abdominal viscera. The position of the placenta is of 
considerable importance. It is more daugerous to the mother when it 
is placed above the foetus than when it is situated below it. In the 
former case, when secondary rupture takes place, the placental tissue 
is likely to give way, and fatal hemorrhage may occur. The density 
and strength of this cyst are found to be very different in different 
cases ; sometimes it forms a complete and strong covering to the ovum, 
at others it is very thin and only partially developed, but it is rarely 
entirely absent. As there is ample space for the development of the 
ovum, and as the secondary cyst generally stretches and grows along with 
it, most cases of abdominal pregnaucy progress without any very remark- 
able symptoms beyond occasional severe attacks of pain, until the full 
term of pregnancy has been reached. Sometimes, however, the cyst lacer- 
ates, and there is an escape of blood into the abdominal cavity, accom- 
panied by more or less prostration and collapse, which may prove fatal, 
but from which the patient more generally rallies. The foetus, now 
dead, will remain in the abdomen, and will undergo changes and produce 
results similar to those which we shall presently describe as occurring 
in cases progressing to the full period, 

In most cases, at the natural termination of pregnancy a strange 
series of phenomena occur ; pseudo-labor comes on, there are more or 
less frequent and strong uterine contractions, possibly an escape of 
blood from the vagina, the discharge of the broken-down uterine 
decidua, and even the establishment of lactation. Sometimes the con- 
tractions of the abdominal muscles produced by this ineffective labor 
have been so strong as to cause the laceration of the adventitious cyst 
surrounding the foetus, and the escape of blood and liquor amnii into 
the abdominal cavity, with a rapidly fatal result. More frequently 
laceration does not occur, and the spurious labor-pains continue at 
intervals, until the foetus dies, possibly from pressure, but more often 
from effusion of blood into the tissue of the placenta, and consequent 
asphyxia. Occasionally the foetus has apparently lived a considerable 
time, in some cases even for several months, after the natural limit of 
pregnancy has been reached. 

Changes after the Death of the Fcetus. — It is after the death of 
the foetus that the dangers of abdominal pregnancy generally com- 
mence, and thev are numerous and various. The subsequent changes 
that occur are well worthy of study. Occasionally the foetus has been 
retained for a leugth of time, even until the end of a long life, without 
producing auv serious discomfort, and in mauy cases of this kind several 
normal nregnancies and deliveries have subsequently taken place. 
Even when the extra-uterine gestation appears to be tolerated, and has 
remained for long without producing any bad effects, serious symptoms 

13 



194 



PREGNANCY. 



Fig. 85. 




Lithopsedion. (From a preparation 
in the Museum of the College of Sur- 
geons.) 



may be suddenly developed ; so that no woman, under such circum- 
stances, can be considered safe. The condition of these retained foetuses 

varies much. Most commonly the liquor 
amnii is absorbed, the foetus shrinks and 
dies, all its soft structures are changed 
into adipocere, and the bones only remain 
unaltered. Sometimes this change occurs 
with great rapidity. I have elsewhere 1 
recorded a case of extra-uterine fcetation 
in which at the full term of pregnancy 
the foetus was alive, and the woman died 
in less than a year afterward. On post- 
mortem examination the foetus was found 
entirely transformed into a greasy mass 
of adipocere, studded with foetal bones, 
in which not a trace of any of the soft 
parts could be detected. On the other 
hand, the foetus may remain unchanged ; 
in the Museum of the College of Surgeons 
there is one which was retained in the 
abdomen for fifty-two years, and which 
was found to be as fresh and unaltered 
as a newborn child. In other cases 
the sac and its contents atrophy and shrink, and calcareous matter is 
deposited in them, so that the whole becomes converted into a solid 
mass known as lithopcedion (Fig. 85). The cases, however, in which 
the retention of the foetus gives rise to no mischief are quite excep- 
tional. Generally the foetus putrefies, and this may either immediately 
cause fatal peritonitis or septicaemia, or, as more commonly happens, 
secondary inflammation and suppuration of the sac. Under the influ- 
ence of the latter the sac opens externally, either directly at some point 
of the abdominal walls, or indirectly through the vagina, the bowels, or 
even the bladder. Through the aperture or apertures thus formed (for 
there are often several fistulous openings), pus, and the bones and other 
parts of the broken-down foetus are discharged ; and this may go on 
for months, and even years, until at last, if the patient's strength does 
not give way, the whole contents of the cyst are expelled, and recovery 
takes place. From various statistical observations it appears that the 
chances of recovery are best when the cyst opens through the abdom- 
inal walls, next through the vagina or bladder, and that the foetus is 
discharged with most difficulty and danger when the aperture is formed 
into the bowel. At the best, however, the process is long, tedious, and 
full of danger ; and the patient too often sinks, during the attempt at 
expulsion, through the irritation and exhaustion produced by the abun- 
dant and long-continued discharge. 

Diagnosis. — The diagnosis of abdominal gestation is by no means 
so easy as might be thought, and the most experienced practitioners 
have been mistaken with regard to it. 



i Obst. Trans., vol. vii., p. 1. 



ABNORMAL PREGNANCY. 195 

The most characteristic symptom, although this is not so common as 
in tubal gestation, is metrorrhagia combined with the general signs of 
pregnancy. Very severe and frequently repeated attacks of abdominal 
pain are rarely absent, and should at once cause suspicion, especially if 
associated with hemorrhage, and the discharge of a decidual membrane 
from the uterus. They are supposed by some to depend on inter- 
current attacks of peritonitis, by which the foetal cyst is formed. Parry 
doubts this explanatiou, and attributes them partly to the distention 
of the cyst by the growing foetus, and partly to pressure on the sur- 
rounding structures. On palpation the form of the abdomen will be 
observed to differ from that of normal pregnancy, being generally 
more developed in the transverse direction, and the rounded outline of 
the gravid uterus cannot be detected. When development has advanced 
nearly to term, the extreme distinctness with which the foetal limbs 
can be felt will arouse suspicion. Per vaginam the os and cervix will 
be felt softened, as in ordinary pregnancy, but often displaced by the 
pressure of the cyst, and sometimes fixed by peri-metritic adhesions ; 
either of these signs is of great diagnostic value. 

By bimanual examination it may be possible to make out that the 
uterus is not greatly enlarged, and that it is distinctly separate from 
the bulk of the tumor : these facts, if recognized, would of themselves 
disprove the existence of uterine gestation. The diagnosis, if the 
foetal limbs or heart-sounds could be detected, would be cleared up in 
any case by the uterine sound, which would show that the uterus was 
empty and only slightly elongated. But we must be careful not to 
resort to this test unless the existence of uterint, gestation is positively 
disproved by other means. As, however, it places the diagnosis beyond 
a doubt, it should always be employed whenever operative procedure 
is in contemplation. I have seen a remarkable case which illustrates 
the importance of this rule. The case had been diaguosed as abdominal 
pregnancy by no less than six experienced practitioners, and was actu- 
ally on the operating-table for the performance of laparotomy. As a 
precaution, having some doubts of the diagnosis, I suggested the pas- 
sage of the sound, which entered into a gravid uterus, the case proving 
to be one of small ovarian tumor jammed down into Douglas' space, 
and displacing the cervix forward. Had it not been for this precau- 
tion its true nature would certainly not have been detected. 

Treatment. — The treatment of abdominal gestation will always be 
a subject of anxious consideration, and there is much difference of 
opinion as to the proper course to pursue. It is becoming more 
generally recognized as good practice, that when the existence of an 
abdominal pregnancy is thoroughly established, no matter what the 
period of pregnancy, the sooner it is operated on the better. Punc- 
turing the cyst, with the view of destroying the foetus and arresting its 
further growth, has been practised, but there are good grounds for 
rejecting it, for there is not the same imminent risk of death from rup- 
ture of the cyst as in tubal fcetation ; and, even if the destruction of the 
foetus could be brought about, there would still be formidable dangers 
from subsequent attempts at elimination, or from internal hemorrhage. 
If the child has perished some form of operation will be required. 



196 PREGNANCY. 

If we have to deal with a case which has advanced nearly to the full 
period, the child being still alive, as proved by auscultation, we have 
to consider whether it may not be advisable to perform laparotomy 
before the foetus perishes, and so at least save the life of the child. 
There are few questions of greater importance and more difficult to 
settle. The tendency of medical opinion is decidely in favor of im- 
mediate operation, which is recommended by Tait, Sutton, and other 
modern writers, whose opinions necessarily carry great weight. The 
arguments used in favor of immediate operation are that while it affords 
a probability of saving the child, the risks to the mother, great though 
they undoubtedly are, are not greater than those which may be antici- 
pated by delay. If we put off interference the cyst may rupture during 
the ineffectual efforts at labor, and death at once ensue; or, if this does 
not take place, other risks, which can never be foreseen, are always in 
store for the patient. She may sink from peritonitis, or from exhaus- 
tion consequent on the efforts at elimination, which in the majority of 
cases are sooner or later set up, so that, as Barnes properly says, u the 
patient's life may be said to be at the mercy of accidents of which we 
have no sufficient warning." Qn the other hand, if we delay, while 
we sacrifice all hope of saving the child, we at least give the mother the 
chance of fcetation remaining quiescent for a length of time, as cer- 
tainly not unfrequently occurs. Thus, Campbell collected 62 cases of 
ultimate recovery after abdominal gestation, in 21 of which the foetus 
was retained without injury for a number of years. Then there is the 
question of secondary laparotomy, which consists in operating after the 
death of the foetus when urgent symptoms have arisen. In favor of 
this procedure it is urged that by delay the inflammation taking place 
about the cyst will have greatly increased the chance of adhesions having 
formed between it and the abdominal parietes, so as to shut off its con- 
tents from the cavity of the peritoneum. The more effectually this has 
been accomplished, the greater are the chances of recovery. When 
the foetus has been dead for some time, the vascularity of the cyst will 
also be lessened, the placental circulation will have ceased, and that 
viscus will have become solid and tough, so that the danger of hemor- 
rhage will be much diminished. 

It will be seen, therefore, that there are arguments in favor of each 
of these views, and the judicious practitioner, in a case far advanced in 
pregnancy, must carefully weigh the attendant circumstances before 
coming to a decision. It is certain, however, that all our most experi- 
enced operators are in favor of operating as soon as possible. In this 
connection the weighty words of Bland Sutton 1 are worthy of quota- 
tion : " The great risk of violent hemorrhage renders an operation for 
tubal pregnancy with a quick placenta between the fifth and ninth 
months of gestation the most dangerous in the whole range of surgery ; 
hence it cannot be urged with too much force that as soon as it is fairly 
evident that a woman has a tubal pregnancy, it should be dealt ivith by 
operation ivithout delay. 

Mode of Performing the Operation. — The operation should be 

} Op. cit., p. 84. 



ABNORMAL PREGNANCY. 197 

performed with all the precautions with which we surround ovariot- 
omy. The incision, best made in the linea alba, should not be greater 
than is necessary to extract the foetus, and may be lengthened as occa- 
sion requires. In cases of sub-peritoneal-abdominal pregnancy the 
peritoneum is lifted up, so that it is often possible to open the gesta- 
tion sac without dividing the peritoneum at all, and whenever this is 
possible it should certainly be done. If there are no adhesions, the 
walls of the cyst should be stitched to the margin of the incision, so as 
to shut it off as completely as possible from the peritoneal cavity. The 
special risk is not so much the wounding of the peritoneum as the sub- 
sequent entrance of septic matter from the cyst into its cavity. It has 
been laid down as a rule that after incising the sac no attempt should 
be made to remove the placeuta. Its attachments are generally so deep- 
seated and diffused that any endeavor to separate it is likely to be at- 
tended with profuse and uncontrollable hemorrhage, or with serious 
injury to the structures to which it is attached. This rule, however, 
must be modified according to circumstances. Sutton is of opinion that 
when the placenta is above the foetus, an attempt should be made to 
remove it, first ligaturing the cord near to its insertion; but when 
below, it should be left. In the former case the placenta is often so 
torn on incising the sac that no option is left to us. The best subse- 
quent course to pursue, after removing the foetus and arresting all hem- 
orrhage, either by ligature or the actual cautery, is to sponge out the 
cyst as gently as possible, sprinkle the cavity with iodoform, or with 
equal parts of tannin and salicylic acid, as recommended by Freund, 1 
and then to bring the upper part of the wound into apposition with 
sutures, leaving the lower open, so as to insure an outlet for the escape 
of the placenta as it slips down ; or the cavity may be lightly stuffed 
with iodoform gauze, which is subsequently changed every third or 
fourth day, until the placenta has come away piecemeal. The subse- 
quent treatment must be specially directed to favor the escape of the 
discharge and to prevent the risk of septicaemia. These objects may 
be much aided by injections of antiseptic fluids, such as solution of 
carbolic acid, or creolin and water ; and it would probably be advis- 
able to place a drainage-tube in the lower angle of the wound. 

Some operators, after removing the foetus and tying the cord, irrigate 
the sac and then close it hermetically, in the hope that the placenta 
may atrophy. There is always, however, the risk of sepsis, which will 
necessitate reopening the sac and endeavoring to remove the placenta 
by a secondary operation. 

As long as the placenta is retained the danger is necessarily great, 
and it may be many days, or even weeks, before it is discharged. 
When once this is effected the sac may be expected to contract, and 
eventually to close entirely. 

Excision of the Cyst. — The more advanced school of operators 
have of late years advised the complete excision of the sac and placenta, 
especially in the primary operation, a procedure which would probably 
be more feasible when gestation has not advanced to term, especially in 

2 Edin. Med. Journ , p. 521. 



198 PREGNANCY. 

cases of sub-peritoneal-abdominal pregnancy, in which the gestation-sac 
has separated the peritoneum from the abdominal wall. This has 
been the course adopted with considerable success by Martin, of Berlin, 
Breisky, of Vienna, and others, and a large number of successful cases 
are now recorded. In this operation, after removing the fcetus, the 
gestation-sac and placenta have been ligatured, bit by bit, and removed, 
without any attempt at tearing or separating the placenta, and thus the 
uncontrollable hemorrhage, which has been so serious a danger when 
the placenta is interfered with, is avoided. This operation is very 
similar, in character, and also in technique, to the enucleation of an 
intra-ligamentary ovarian cyst. It is needless to point out that such 
a procedure is only likely to succeed in the hands of operators thor- 
oughly self-reliant and conversant with the details of abdominal sur- 
gery. Under such conditions, since it materially lessens the risk of 
septic infection, which must always be excessive when the cyst and 
placenta remain in the abdomen, it is clearly the most hopeful resource, 
and as experience increases it will probably be more extensively used. 

Treatment. — When the fcetus is dead, or when we have determined 
not to attempt primary laparotomy, it is advisable to wait, very care- 
fully watching the patient, until either the gravity of her general 
symptoms, or some positive indication of the channel through which 
Nature is about to attempt to eliminate the foetus, shows us that the 
time for action has arrived. If there be distinct bulging of the cyst 
in the vagina, or in the retro-uterine cul-de-sac, especially if an open- 
ing has formed there, we may properly content ourselves with aiding 
the passage of the fcetus through the channel thus indicated, and re- 
moving the parts that present piecemeal as they come within reach, 
cautiously enlarging the aperture if necessary. If the sac have opened 
into the intestines, the expulsion of the fcetus through this channel is 
so tedious and difficult, the exhaustion attending it so likely to prove 
fatal, and the danger from decompositon of the foetus through passage 
of intestinal gas so great, that it would probably be best to attempt to 
remove it by laparotomy, especially if it is only recently dead, and the 
greater portion is still retained. 

Mode of Performing Secondary Laparotomy. — If an opening 
forms at the abdominal parietes, or if the symptoms determine us to 
resort to secondary laparotomy before this occurs, the operation must 
be performed in the same way, and with the same precautions as pri- 
mary laparotomy. This operation is not only more simple, but much 
more successful than the primary. Bland Sutton 1 gives a list of seven 
cases operated on after the death of the foetus at or near term, in all 
of which the mothers recovered. This is doubtless due to changes in 
the placental circulation, which render its connections much less vascu- 
lar and facilitate its separation, and these are believed to be completed 
about ten weeks after foetal death, so that the operation should be post- 
poned, if possible, until that time has elapsed after the supposed death 
of the child. Under these conditions the placenta can be removed at 
the time of the operation with much less risk of hemorrhage. Here, 

1 Surgical Diseases of the Ovaries and Fallopian Tubes, p. 425. 



ABNORMAL PREGNANCY. 199 

as before, the safety of the operation must greatly depend on the 
amount and firmness of the adhesions ; for if the cyst be not com- 
pletely shut off from the peritoneal cavity, the risks of the operation 
will be little less than those of primary laparotomy. It would ob- 
viously materially influence our decision and prognosis if we could de- 
termine this point before operating. Unfortunately, it is impossible, 
as the experience of ovariotomists proves,- to ascertain the existence of 
adhesions with any certainty. If, however, we find that the abdominal 
parietes do not move freely over the cyst, and if the umbilicus be de- 
pressed and immovable, the presumption is that considerable adhesions 
exist. If they are found not to be present, the cyst walls should 
be stitched to the margin of the incision, in the manner already indi- 
cated, before the contents are removed. 

If the foetus has been long dead, and its tissues greatly altered, its re- 
moval may be a matter of difficulty. In the case under my own care, 
already alluded to, the foetal structures formed a sticky mass of such 
a nature that I believe it would have been impossible to empty the cyst 
had an operation been attempted. 

Opening- of cyst by Caustics. — The importance of adhesions has 
led some practitioners to recommend the opening of the cyst by potassa 
fusa or some other caustic, in the hope that it would set up adhesive 
inflammation around the aperture thus formed. If we have to deal 
with a case in which fistulous openings leading to the cyst have already 
formed, it may, perhaps, be advisable to dilate the existing apertures 
rather than make a fresh incision ; but, in determining this point, the 
surgeon will naturally be guided by the nature of the case and the 
character and direction of the fistulous openings. 

General Treatment. — It is almost needless to say anything of 
general treatment in these trying cases ; but the administration of 
opiates to allay the sufferings of the patient, and the endeavor to sup- 
port the severely taxed vital energies by appropriate food and medica- 
tion, will form a most important part of the management. Freund 
specially insists on the importance of careful regulation of the bowels, 
and on making milk the staple article of diet, as important points in 
the management of cases prior to operation. 

Gestation in a Bi-lobed Uterus. — A few words may be said as to 
gestation in the rudimentary horn of a bi-lobed uterus, to which con- 
siderable attention has of late years been directed by the writings of 
Kussmaul and others. It appears certain that many cases of supposed 
tubal gestation are really to be referred to this category. Although 
such cases are of interest pathologically, they scarcely require much 
discussion from a practical point of view, inasmuch as their history is 
pretty nearly identical with that of tubal pregnancy c The rudimentary 
horn is distended by the enlarging ovum, and after a time, when further 
distention is impossible, laceration takes place. As a matter of fact, all 
the thirteen cases collected by Kussmaul terminated in this way ; and 
even on post-mortem examination it is often extremely difficult to dis- 
tinguish them from tubal pregnancies. The best way of doing so is 
probably by observing the relations of the round ligament to the 
tumor; for, if the gestation be tubal, it will be found attached to the 



200 



PREGNANCY, 



uterus on the inner or uterine side of the cyst; whereas, if the preg- 
nancy be in a rudimentary horn of the uterus, it will be pushed out- 
ward, and be external to the sac. In the latter case, moreover, the 
sac will be probably found to contain a true decidua, which is not the 
case in tubal pregnancy. The chief point in which they differ is that 
in cornual pregnancy, rupture may be delayed to a somewhat later 
period than in tubal, on account of the greater distensibility of the 
supplementary horn. 



Fig. 86. 




Contents of the cyst in Dr. Oldham's case of missed labor. 

Missed Labor. — The term "missed labor v is applied to an exceed- 
ingly rare class of cases in which, at the full period of pregnancy, 
labor has either not come on at all, or, having commenced, the pains 
have subsequently passed off, and the foetus is retained in utero for a 
very considerable length of time. Under such circumstances it has 
usually happened that the membranes have ruptured at or about the 
proper term, and the access of air to the foetus in utero has been followed 
by decomposition. A putrid and offensive discharge has then com- 
menced, and eventually portions of the disintegrating foetus have been 
expelled per vaginam. This discharge may go on until the entire foetus 
is gradually thrown off; or, more frequently the patient dies from sep- 
ticaemia, or other secondary result of the presence of the decomposing 
mass in utero. Thus McClintock relates one case, 1 in which symptoms 
of labor came on in a woman, forty-five years of age, at the expected 
period of delivery, but passed off without the expulsion of the foetus. 



» Dublin Quarterly Journal, Feb. and May, 1864 



ABNORMAL PREGNANCY. 201 

For a period of sixty-seven weeks a highly offensive discharge came 
away, with some few bones, and she eventually died with symptoms 
of pyaemia. He also cites another case in which the patient died in 
the same way, after the foetus had been retained for eleven years. 

Sometimes when the foetus has been retained for a length of time, a 
further source of danger has been added by ulceration or destruction 
of the uterine walls, probably in consequence of an ineffectual attempt 
at its elimination. This occurred in Dr. Oldham's case (Fig. 86), in 
which the contained mass is said to have nearly worn through the 
anterior wall of the uterus ; and also in one reported by Sir James 
Simpson, 1 in which a patient died three months after term, the foetus 
having undergone fatty metamorphosis, an opening the size of half-a- 
crown having formed between the transverse colon and the uterine 
cavity. It is also stated that "the uterine Malls were as thin as 
parchment." 

In some few cases, however, probably when the entrance of air has 
been prevented, the foetus has been retained for a length of time with- 
out decomposing, and without giving rise to any troublesome symp- 
toms. Such a case is reported by Dr. Cheston, 2 in which the foetus 
remained in utero for fifty-two years. 

The causes of this strange occurrence are altogether unknown. 
Generally the foetus seems to have died some time before the proper 
term for labor, and this may have influenced the character of the 
pains. It is probably also most apt to occur in women of feeble and 
inert habit of body, possibly where there was some obstacle to the 
dilatation of the cervix, which the pains were unable to overcome. 
Barnes suggests 3 that some presumed examples of missed labor "were 
really cases of interstitial gestation, or gestation in one horn of a 
two-horned uterus; " and Macdonald* has recorded a very interesting 
case in which he performed laparotomy for what he believed to be a 
uterine fibroid, but which turned out to be one horn of a bifurcated 
uterus containing a foetus which had been retained for more than a 
year. He believes that most, if not all, cases of " missed labor" are 
of this kind, delivery at term proving impossible because of the narrow 
connection between the impregnated horn and the cervix. 

Miiiler, of Xancy, has attempted to prove, by a critical examination 
of published cases, s that most examples of so-called "missed labor" 
were in reality cases of extra-uterine foetation, in which an ineffectual 
attempt at parturition took place, the foetus being subsequently re- 
tained. 

From what has been said, it will be seen that the dangers arising 
from this state are very considerable, and when once the full term has 
passed beyond doubt, especially if the presence of an offensive discharge 
shows that decomposition of the foetus has commenced, it would be 
proper practice to empty the uterus as soon as possible. The necessary 
precaution, however, is not to decide too quickly that the term has 
really passed ; and, therefore, we must either allow sufficient time to 

1 Edin. Med. Journal, 1865. 2 Med.-Chir. Trans., 1814. 

3 Diseases of Women, p. 445. 

* Edin. Med. Journ., p. 873. 

6 De la Grossesse uterine prolongee indefiniment, Paris, 1878. 



202 PREGNANCY. 

elapse to make it quite certain that the case really falls under this 
category, or have unequivocal signs of the death of the foetus, and 
injury to the mother's health. 

Treatment. — If we had to deal with the case before any exten- 
sive decomposition of the foetus had occurred, we probably should 
find little difficulty in its management, for the proper course then 
would be to dilate the cervix, and remove the foetus by turning ; 
or, before doing so, we might endeavor to excite uterine action by 
pressure and ergot. If the case did not come under observation until 
disintegration of the foetus had begun, it would be more difficult to 
deal with. If the foetus had become so much broken up that it was 
being discharged in pieces, Dr. McClintock says that " in regard to 
treatment, our measures should consist mainly of palliatives, viz., rest 
and hip-baths, to subdue uterine irritation ; vaginal injections, to secure 
cleanliness and prevent excoriation ; occasional digital examination so 
as to detect any fragments of bone that might be presenting at the os, 
and to assist in removing them. These are plain rational measures, 
and beyond them we shall scarcely, perhaps, be justified in venturing. 
Nevertheless, under certain circumstances, I would not hesitate to dilate 
the cervical canal so as to permit of examining the interior of the womb, 
and of extracting any fragments of bone that may be easily accessible ; 
but unless they could thus be easily reached and removed, the safer 
course would be to defer, for the present, interfering with them." 1 

It may be doubted, I think, whether, considering the serious results 
which are known to have followed so many cases, it would not, on the 
whole, be safer to make at least one decided effort, under chloroform, 
to remove as much as possible of the putrefying uterine contents, after 
the os has been fully dilated. Such a procedure would be less irri- 
tating than frequently repeated endeavors to pick away detached por- 
tions of the foetus, as they present at the os uteri. When once the 
os is dilated, antiseptic intra-uterine injections might be safely and 
advantageously used. Unquestionably, it would be better practice to 
interfere and empty the uterus as soon as we are quite satisfied of the 
nature of the case, rather than to delay until the foetus has been dis- 
integrated. Macdonald thinks that abdominal section would be the 
best course to pursue, either removing the sac entire or resorting to 
Porro's operation. This advice is based on the assumption that 
"missed labor" is essentially the retention of a foetus in one horn 
of a bi-lobed uterus, a theory which certainly cannot yet be taken as 
proved. 

1 Dublin Quart. Journ., vol. xxxvii, p. 314. 



DISEASES OF PREGNANCY. 203 



CHAPTEE' VII. 

DISEASES OF PREGNANCY. 

The diseases of pregnancy form a subject so extensive that they 
might well of themselves furnish ample material for a separate treatise. 
The pregnant woman is, of course, liable to the same diseases as the 
non-pregnant ; but it is only necessary to allude to those whose course 
and eifects are essentially modified by the existence of pregnancy, or 
which have some peculiar effect on the patient in consequence of her 
condition. There are, moreover, many disorders which can be dis- 
tinctly traced to the existence of pregnancy. Some of them are the 
direct results of the sympathetic irritations which are then so commonly 
observed ; and, of these, several are only exaggerations of irritations 
which may be said to be normal accompaniments of gestation. These 
functional derangements may be classed under the head of neuroses, 
and they are sometimes so slight as merely to cause temporary incon- 
venience, at others so grave as seriously to imperil the life of the 
patient. Another class of disorders is to be traced to local causes in 
connection with the gravid uterus, and are either the mechanical 
results of pressure, or of some displacement or morbid state of the 
uterus ; while the origin of others may be said to be complex, being 
partly due to sympathetic irritation, partly to pressure, and partly to 
obscure nutritive changes produced by the pregnant state. 

Derangements of the Digestive System. — Among the sympa- 
thetic derangements there are none which are more common, and none 
which more frequently produce distress, and even danger, than those 
which affect the digestive system. Under the heading of " The Signs 
of Pregnancy," the frequent occurrence of nausea and vomiting has 
already been discussed, and its most probable causes considered (p. 151). 
A certain amount of nausea is, indeed, so common an accompaniment of 
pregnancy that its consideration as one of the normal symptoms of thai 
state is fully justified. AVe need here only discuss those cases in which 
the nausea is excessive and long-continued, and leads to serious results 
from inanition and from the constant distress it occasions. Fortunately 
a pregnant woman may bear a surprising amount of nausea and sickness 
without constitutional injury, so that apparently almost all aliments 
may be rejected without the nutrition of the body very materially suf- 
fering. At times the vomiting is limited to the early part of the day, 
when all food is rejected, and when there is a frequent retching of glairy 
transparent fluid, in several cases mixed with bile, while at the latter 
part of the day the stomach may be able to retain a sufficient quantity 
of food, and the nausea disappears. In other cases the nausea and 
vomiting are almost incessant. The patient feels constantly sick, and 



204 PREGNANCY. 

the mere taste or sight of food may 'bring on excessive and painful 
vomiting. The duration of this distressing accompaniment of preg- 
nancy is also variable. Generally it commences between the second 
and third months, and disappears after the woman has quickened. 
Sometimes, however, it begins with conception, and continues unabated 
until the pregnancy is over. 

Symptoms of the Graver Cases. — In the worst class of cases, 
when all nourishment is rejected, and when the retching is continuous 
and painful, symptoms of very great gravity, which may even prove 
fatal, develop themselves. The countenance becomes haggard from 
suffering, the tongue dry and coated, the epigastrium tender on press- 
ure, and a state of extreme nervous irritability, attended with, restless- 
ness and loss of sleep, becomes established. In a still more aggravated 
degree, there is general feverishness, with a rapid, small, and thready 
pulse. Extreme emaciation supervenes, the result of wasting from 
lack of nourishment. The breath is intensely fetid, and the tongue 
dry and black. The vomited matters are sometimes mixed with blood. 
The patient becomes profoundly exhausted, a low form of delirium 
ensues, and death may follow if relief is not obtained. 

Prognosis. — Symptoms of such gravity are fortunately of extreme 
rarity, but they do from time to time arise, and cause much anxiety. 
Gueniot collected 118 cases of this form of the disease, out of which 
46 died ; and out of the 72 that recovered, in 42 the symptoms only 
ceased when abortion, either spontaneous or artificially produced, had 
occurred. When pregnancy is over, the symptoms occasionally cease 
with marvellous rapidity. The power of retaining and assimilating 
food is rapidly regained, and all the threatening symptoms dis- 
appear. 

Treatment. — In the milder forms of obstinate vomiting, one of the 
first indications will be to remedy any morbid state of the primse vise. 
The bowels will not unfrequently be found to be obstinately consti- 
pated, the tongue loaded, and the breath offensive ; and when attention 
has been paid to the general state of the digestive organs by aperient 
medicines and antacid remedies, such as bismuth and soda and liquor 
pepticus after meals, the tendency to vomiting may abate without 
further treatment. 

The careful regulation of the diet is very important. Great benefit 
is often derived from recommending the patient not to rise from the 
recumbent position in the morning until she has taken something. 
Half a cup of milk and lime-water, or a cup of strong coffee, or a 
little rum and milk, or cocoa and milk, a glass of sparkling koumiss, 
or even a morsel of biscuit, taken on waking, often has a remarkable 
effect in diminishing the nausea. When any attempt at swallowing 
solid food brings on vomiting, it is better to give up all pretence at 
keeping to regular meals, and to order such light and easily assimilated 
food, at short intervals, as can be retained. Iced milk, with lime- 
or soda-water, not more than a mouthful at a time, will frequently 
be retained when nothing else will. Cold beef-jelly, a spoonful 
at a time, will also be often kept down. Sparkling koumiss has 
been strongly recommended as very useful in such cases, and is 



DISEASES OF PREGNANCY. 205 

worthy of trial. It is well, however, to bear in mind, in regulating 
the diet, that the stomach is fanciful and capricious, and that the 
patient may be able to retain strange and apparently unlikely articles 
of food ; and that, if she express a desire for such, the experiment of 
letting her have them should certainly be tried. 

The medicines that have been recommended are innumerable, and 
the practitioner will often have to try oue after the other unsuccess- 
fully ; or may find, in an individual case, that a remedy will prove 
valuable which, in another, may be altogether powerless. Amongst 
those most generally useful are effervescing draughts, containing from 
three to five minims of dilute hydrocyanic acid ; the creosote mixture 
of the Pharmacopoeia ; tincture of mix vomica, in doses of five or ten 
minims ; single minim doses of vinum ipecacuanha?, every hour in severe 
cases, three or four times daily in those which are less urgent ; salicine, 
in doses of three to five grains three times a day, recommended by 
Tyler Smith; oxalate of cerium, in the form of a pill, of which three 
to five grains may be given three times a day — a remedy strongly 
advocated by Sir James Simpson, and which occasionally is of un- 
doubted service, but more often fails; the compound pyroxylic spirit 
of the London Pharmacopoeia, in doses of five minims every four 
hours, with a little compound tincture of cardamoms, a drug which is 
comparatively little known, but w-hich occasionally has a very marked 
and beneficial effect in checking vomiting; opiates in various forms — 
which sometimes prove useful, more often not — may be administered 
either by the mouth, in pills containing from half a grain to a grain 
of opium, or in small doses of the solution of the bi-meconate of 
morphia or of Battley's sedative solution, or subcutaneously, a mode 
of administration which is much more often successful. The hydro- 
chlorate of cocaine is said to be very efficacious; two grains are dis- 
solved in five ounces of water, by means of spirit, of which mixture 
a teaspoonful may be taken every hour. Menthol has been highly 
recommended by Gottshalk, 1 in doses of about two grains every hour. 
Antipyriue in ten-grain doses has sometimes proved useful. If there 
is much tenderness about the epigastrium, one or two leeches may be 
advantageously applied, or one-third of a grain of morphia may be 
sprinkled on the surface of a small blister, or cloths saturated in 
laudanum may be kept over the pit of the stomach. The administra- 
tion per rectum of twenty grains of chloral, combined with the same 
amount of bromide of potassium, in small enema, is said to be very 
useful. In many cases I have found that the application of a spinal 
ice-bag to the cervical vertebra?, in the manner recommended by Dr. 
Chapman, has checked the vomiting when all drugs have failed. The 
ice may be placed in one of Chapman's spinal ice-bags, and applied 
for half an hour or an hour, twice or three times a day. It invariably 
produces a comforting sensation of warmth, which is always" agreeable 
to the patient. Ice may be given to suck ad libitum, and is very 
useful ; while if there be much exhaustion, small quantities of iced 
champagne may also be given from time to time. The application of 
the ether spray over the epigastrium has been highly recommended. 

i Der Frauenarzt, March, 1891. 



206 PREGNANCY. 

Inasmuch as the vomiting unquestionably has its origin in the 
uterus, it is only natural that practitioners should endeavor to check 
it by remedies calculated to relieve the irritability of that organ. Thus 
morphia in the form of pessaries per vaginam, or belladonna applied 
to the cervix, have been recommended, and — the former especially — are 
often of undoubted service. A pessary containing one-third to half a 
grain of morphia may be introduced night and morning without in- 
terfering with other methods of treatment. Dr. Henry Bennet directed 
especial attention to the cervix, which, he says, is almost always con- 
gested and inflamed, and covered with granular erosions. This con- 
dition he recommends to be treated by the application of nitrate of 
silver through the speculum. Amand Routh has recently spoken 
highly of the good effects of painting the cervix with a strong solution 
of iodine. 1 Dr. Clay, of Manchester, advocated, especially when vom- 
iting continues in the latter months, the application of one or two 
leeches to the cervix. Exception may fairly be taken to these methods 
of treatment as being somewhat hazardous, unless other means have 
been tried and failed. I have little doubt, however, that in many 
cases a state of uterine congestion is an important factor in keeping 
up the unduly irritable condition of the uterine fibres, and an endeavor 
should always be made to lessen it by insisting on absolute rest in the 
recumbent posture. Of the importance of this precaution in obstinate 
cases there can be no question. Dr. Copeman, of Norwich, strongly 
recommended dilatation of the cervix by the finger, and stated that he 
found it very serviceable in checking nausea. It is obvious that this 
treatment must be adopted with great caution, as, roughly performed, 
it might lead to the production of abortion. Dr. Hewitt's views as 
to the dependence of sickness on flexions of the uterus have already 
been adverted to, and reasons have been given for doubting the gen- 
eral correctness of his theory. It is quite likely, however, that well- 
marked displacements of the uterus, either forward or backward, may 
serve to intensify the irritability of the organ. Cazeaux mentions an 
obstinate case immediately cured by replacing a retroverted uterus. A 
careful vaginal examination should, therefore, be instituted in all 
intractable cases, and if distinct displacement be detected, an endeavor 
should be made to support the uterus in its normal axis. If retro- 
verted, a Hodge's pessary may be safely employed ; if anteverted, a 
small air-ball pessary, as recommended by Hewitt, should be inserted. 
I believe, however, that such displacements are the exception, rather 
than the rule, in cases of severe sickness. 

The importance of promoting nutrition by every means in our power 
should always be borne in mind. The effervescing koumiss, which can 
now be readily obtained, I have found of great value, as it can often 
be retained when all other aliment is rejected. The exhaustion pro- 
duced by want of food soon increases the irritable state of the nervous 
system, and, if the stomach will not retain anything, we can only 
combat it by occasional nutrient enemata of strong beef-tea, yolk of 
eggj and the like. 

i Brit. Med. Journ., JuneG, 1891. 






DISEASES OF PREGNANCY. 207 

The Production of Artificial Abortion. — Finally, in the worst 
class of cases, when all treatment has failed, and when the patient has 
fallen into the condition of extreme prostration already described, Ave 
may be driven to consider the necessity of producing abortion. For- 
tunately cases justifying this extreme resource are of great rarity, but 
nevertheless there is abundant evidence that every now and then women 
do die from uncontrollable vomiting whose lives might have been saved 
had the pregnancy been brought to an end. The value of artificial 
abortion has been abundantly proved. Indeed, it is remarkable how 
rapidly the serious symptoms disappear when the uterus is emptied, 
and the tension of the uterine fibres lessened. It has fortunately but 
rarely fallen to my lot to have to perform this operation for intractable 
vomiting. In one such case the patient was reduced to a state of the 
utmost prostration, having kept hardly any food on her stomach for 
many weeks, and when I first saw her she was lying in a state of low 
muttering delirium. Within a few hours after abortion was induced 
all the threatening symptoms had disappeared, the vomiting had entirely 
ceased, and she was next day able to retain and absorb all that was 
given to her. The value of the operation, therefore, I believe to be 
undoubted. Where it has failed it seems to have been on account of 
undue delay. Owing to the natural repugnance which all must feel 
toward this plan, it has generally been postponed until the patient has 
been too exhausted to rally. If, therefore, it is done at all, it should 
be before prostration has advanced so far as to render the operation 
useless. In these cases the obvious indication is to lessen the tension 
of the uterus at once, and, therefore, the membranes should be punc- 
tured by the uterine sound, so as to let the liquor amnii drain away, 
and this may of itself be sufficient to accomplish the desired effect. It 
is almost needless to add, that no one would be justified in resorting to 
this expedient without having his opinion fortified by consultation with 
a fellow-practitioner. 

Other disorders of the digestive system may give rise to con- 
siderable discomfort, but not to the serious peril attending obstinate 
vomiting. Amongst them are loss of appetite, acidity and heartburn, 
flatulent distention, and sometimes a capricious appetite, which assumes 
the form of longing for strange and even disgusting articles of diet. 
Associated with these conditions there is generally derangement of the 
whole intestinal tract, indicated by furred tongue and sluggish bowels, 
and they are best treated by remedies calculated to restore a healthy 
condition of the digestive organs, such as a light, easily digested diet, 
mineral acids, vegetable bitters, occasional aperients, bismuth and soda, 
and pepsin. The indications for treatment are not different from those 
which accompany the same symptoms in the non-pregnant state. 

Diarrhoea is an occasional accompaniment of pregnancy, often 
depending on errors of diet. When excessive and continuous it has a 
decided tendency to induce uterine contractions, and I have frequently 
observed premature labor to follow a sharp attack of diarrhoea. It 
should, therefore, not be neglected ; and if at all excessive, should be 
checked by the usual means, such as chalk mixture with aromatic con- 
fection, and small doses of laudanum or chlorodyne. The possibility 



208 PREGNANCY. 

of apparent diarrhoea being associated with actual constipation, the 
fluid matter finding its way past the solid materials blocking up the 
intestines, should be borne in mind. 

Constipation is much more common, and is indeed a very general 
accompaniment of pregnancy, even in women who do not suffer from 
it at other times. It partly depends on the mechanical interference of 
the gravid uterus with the proper movements of the intestines, and 
partly on defective innervation of the bowels resulting from the altered 
state of the blood. The first indication will be to remedy this defect 
by appropriate diet, such as fresh fruits, brown bread, oatmeal por- 
ridge, etc. Some medicinal treatment will also be necessary, and, in 
selecting the drugs to be used, care should be taken to choose such as 
are mild and unirritating in their action, and tend to improve the 
tone of the muscular coat of the intestine. A small quantity of 
aperient mineral water in the early morning, such as the Hunyadi, 
Friedrichshall, or Pullna water, often answers very well ; or com- 
pound sulphur lozenge ; or a pill containing three or four grains of 
the extract of colocynth, with a quarter of a grain of the extract of 
dux vomica and a grain of extract of hyoscyamus, at bedtime ; or a 
teaspoonful of the compound liquorice powder in milk at bedtime. 
Constipation is also sometimes effectually combated by administering, 
twice daily, a pill containing a couple of grains of the inspissated ox- 
gall, with a quarter of a grain of extract of belladonna. Enemata of 
soap and water are often very useful, and have the advantage of not 
disturbing the digestion. In the latter months of pregnancy, especially 
in the few weeks preceding delivery, the irritation produced by the 
collection of hardened feces in the bowel is a not infrequent cause of 
the annoying false pains which then so commonly trouble the patient. 
In order to relieve them, it will be necessary to empty the bowels 
thoroughly by an aperient, such as a good dose of castor oil, to which 
fifteen or twenty minims of laudanum may be advantageously added. 
Should the rectum become loaded with scybalous masses, it may be 
necessary to break down and remove them by mechanical means, 
provided we are unable to effect this by copious enemata. 

Hemorrhoids. — The loaded state of the rectum so common in preg- 
nancy, combined with the mechanical effect of the pressure of the 
gravid uterus on the hemorrhoidal veins, often produces very trouble- 
some symptoms from piles. In such cases a regular and gentle evacu- 
ation of the bowels should be secured daily, so as to lessen as much as 
possible the congestion of the veins. Any of the aperients already 
mentioned, especially the sulphur electuary, may be used. Dr. For- 
dyce Barker 1 insists that, contrary to the usual impression, one of the 
best remedies for this purpose is a pill containing a grain or a grain 
and a half of powdered aloes, with a quarter of a grain of extract of 
nux vomica, and that castor oil is distinctly prejudicial, and apt to 
increase the symptoms. I have certainly found it answer well in 
several cases. When the piles are tender and swollen, they should be 
freely covered with an ointment consisting of four grains of muriate of 

1 The Puerperal Diseases, p. 33: 






DISEASES OF PREGNANCY. 209 

morphia to an ounce of simple ointment, or with the img. gallse cum 
opio of the Pharmacopoeia ; and, if protruded, an attempt should be 
made to push them gently above the sphincter, by which they are 
often unduly constricted. Relief may also be obtained by frequent 
hot fomentations, and sometimes, when the piles are much swollen, it 
will be found useful to puncture them, so as to lessen the congestion, 
before any attempt at reduction is made. 

Ptyalism. — A profuse discharge from the salivary glands is an occa- 
sional distressing accompaniment of pregnancy. It is generally con- 
fined to the early months, but it occasionally continues during the 
whole period of gestation, and resists all treatment, only ceasing when 
delivery is over. Under such circumstances the discharge of saliva is 
sometimes enormous, amounting to several quarts a day, and the dis- 
tress and annoyance to the patient are very great. In one case under 
my care the saliva poured from the mouth all day long, and for several 
months the patient sat with a basin constantly by her side, incessantly 
emptying her mouth, until she was reduced to a condition giving rise 
to really serious auxietv. This profuse salivation is, no doubt, a purely 
nervous disorder, and not readily controlled by remedies. Astringent 
gargles, containing tannin and chlorate of potash, frequent sucking of 
ice or of tannin lozenges, inhalation of turpentine and creosote, counter- 
irritation over the salivary glands by blisters or iodine, the continuous 
galvanic current applied over the parotids, the bromides, opium inter- 
nally, small doses of belladonna or atropine, may all be tried in turn, 
but none of them can be depended on with any degree of confidence. 

Toothache and Caries of the Teeth. — Severe dental neuralgia is 
also a frequent accompaniment of pregnancy, especially in the early 
months. When purely neuralgic, quinine in tolerably large doses is 
the best remedy at our disposal ; but not unfrequently it depends on 
actual caries of the teeth, and attention should always be paid to the 
condition of the teeth when facial neuralgia exists. There is no doubt 
that pregnancy predisposes to caries, and the observation of this fact 
has given rise to the old proverb, " For every child a tooth. " Mr. 
Oakley Coles, in an interesting paper 1 on the condition of the mouth 
and teeth during pregnancy, refers the prevalence of caries to the co- 
existence of acid dyspepsia, causing acidity of the oral secretions. 
There is much unreasonable dread amougst practitioners as to inter- 
fering with the teeth during pregnancy, and some recommend that all 
operations, even filling, should be postponed until after delivery. 
It seems to me certain that the suffering of severe toothache is likely 
to give rise to far more severe irritation than the operation required 
for its relief, and I have frequently seen badly decayed teeth extracted 
during pregnancy, and with only a beneficial result. 

Affections of the Respiratory Organs. — Amongst the derange- 
ments of the respiratory organs, one of the most common is spasmodic 
cough, which is often excessively troublesome. Like many other of 
the sympathetic derangements accompanying gestation, it is purely 
nervous in character, and is unaccompanied by elevated temperature, 

1 Trans, of the Odontological Society. 
14 



210 PREGNANCY. 

quickened pulse, or any distinct auscultatory phenomena, in character 
it is not unlike whooping-cough. The treatment must obviously be 
guided by the character of the cough. Expectorants are not likely to 
be of service, while benefit may be derived from some of the anti- 
spasmodic class of drugs, such as belladonna, hydrocyanic acid, opiates, 
or bromide of potassium. Such remedies may be tried in succession, 
but will often be found to be of little value in arresting the cough. 
Dyspnoea may also be nervous in character, and sometimes symptoms 
not unlike those of spasmodic asthma are produced. Like the other 
sympathetic disorders, it, as well as nervous cough, is most frequently 
observed during the early months. There is another form of dyspnoea, 
not uncommonly met with, which is the mechanical result of the inter- 
ference with the action of the diaphragm and lungs by the pressure of 
the enlarged uterus. Hence this is most generally troublesome in the 
latter months, and continues unrelieved until delivery, or until the 
sinking of the uterine tumor which immediately precedes it. Beyond 
taking care that the pressure is not increased by tight lacing or injudi- 
cious arrangement of the clothes, there is little that can be done to 
relieve this form of breathlessness. 

Palpitation. — Palpitation, like dyspnoea, may be due either to sym- 
pathetic disturbance, or to mechanical interference with the proper 
action of the heart. When occurring in weakly women it may be 
referred to the functional derangements which accompany the chlorotic 
condition of the blood often associated with pregnancy, and is then 
best remedied by a general tonic regimen, and the administration of 
ferruginous preparations. At other times anti-spasmodic remedies may 
be indicated, and it is seldom sufficiently serious to call for much 
special treatment. 

Syncope. — Attacks of fainting are not rare, especially in delicate 
women of highly developed nervous temperament, and are, perhaps, 
most common at or about the period of quickening. In most cases 
these attacks cannot be classed as cardiac, but are more probably 
nervous in character, and they are rarely associated with complete 
abolition of consciousness. They rather, therefore, resemble the condi- 
tion described by the older authors as Leipothymia. The patient lies 
in a semi-unconscious condition with a feeble pulse and widely dilated 
pupils, and this state lasts for varying periods, from a few minutes to 
half an hour or more. In one very troublesome case under my care 
they often recurred as frequently as three or four times a day. I have 
•observed that they rarely occur when the more common sympathetic 
phenomena of pregnancy, especially vomiting, are present. Sometimes 
they terminate with the ordinary symptoms of hysteria, such as sob- 
bing. The treatment should consist during the attack in the adminis- 
tration of diffusible stimulants, such as ether, salvolatile, and valerian, 
the patient being placed in the recumbent position, with the head low. 
If frequently repeated it is unadvisable to attempt to rally the patient 
by the too free administration of stimulants. In the intervals a gener- 
ally tonic regimen, and the administration of ferruginous remedies, 
are indicated. If they recur with great frequency, the daily applica- 
tion of the spinal ice-bag has proved of much service. 



DISEASES OF PEEGNANCY. 211 

Extreme Ansemia and Chlorosis. — In connection with disorders 
of the circulatory system may be noticed those which depend on the 
state of the blood. The altered condition of the blood, which has 
already been described as a physiological accompaniment of pregnancy 
(p. 147), is sometimes carried to an extent which may fairly be called 
morbid j and either on account of the deficiency of blood corpuscles, 
or from the increase in its watery constituents, a state of extreme 
anaemia and chlorosis may be developed. This may be sometimes 
carried to a very serious extent, the condition amounting to that 
known as " pernicious ansemia." Thus Gusserow 1 records five cases, 
in which nothing but excessive anaemia could be detected, all of which 
ended fatally. Generally when such symptoms have been carried to 
an extreme extent, the patient has been in a state of chlorosis before 
pregnancy. In cases of this aggravated type the patient will prob- 
ably miscarry, and the induction of premature labor or abortion may 
even become imperative. 

Treatment. — The treatment must, of course, be calculated to im- 
prove the general nutrition, and enrich the impoverished blood ; a light 
and easily assimilated diet, milk, eggs, beef-tea, and animal food — if 
it can be taken ; attention to the proper action of the bowels, a due 
amount of stimulants, and abundance of fresh air, will be the chief 
indications in the general management of the case. Medicinally, 
ferruginous preparations will be required. Some practitioners object, 
apparently without sufficient reason, to the administration of iron 
during pregnancy, as liable to promote abortion. This unfounded 
prejudice may probably be traced to the supposed emmenagogue prop- 
erties of the preparations of iron; but, if the general condition of 
the patient indicate such medication, they may be administered without 
any fear. Preparations of phosphorus, such as the phosphide of zinc, 
or free phosphorus, also promise favorably, and are well worthy of 
trial. 

Some of the more aggravated cases are associated with a consider- 
able amount of serous effusion into the cellular tissue, generally limited 
to the lower extremities, but occasionally extending to the arms, face, 
and neck, and even producing ascites and pleuritic effusion. Under 
the latter circumstances this complication is, of course, of great gravity, 
and it is said that after delivery the disappearance of the serous effusion 
may be accompanied by metastasis of a fatal character to the lungs or 
the nervous centres. This form of oedema must be distinguished from 
the slight cedematous swelling of the feet and legs so commonly ob- 
served as a mechanical result of the pressure of the gravid uterus, and 
also from those cases of oedema associated with albuminuria. The 
treatment must be directed to the cause, while the disappearance of the 
effusion may be promoted by the administration of diuretic drinks, the 
occasional use of saline aperients, and rest in the horizontal position. 

Albuminuria. — The existence of albumin in the urine of pregnant 
women has for many years attracted the attention of obstetricians, and 
it is now well known to be associated, in ways still imperfectly junder- 

i Arch. f. Gyn., Bd. ii. S. 218. 



212 PREGNANCY. 

stood, with many important puerperal diseases. Its presence in most 
eases of puerperal eclampsia was long ago pointed out by Lever in 
this country and Rayer in France, and its association with this disease 
gave rise to the theory of the dependence of the convulsion on uraemia. 
It has been shown, especially by Braxton Hicks, that this association is 
by no means so universal as was supposed; or rather, that in some cases 
the albuminuria follows and does not precede the convulsions, of which 
it might therefore be supposed to be the consequence rather than the 
cause ; so that further investigations as to these particular points are 
still required. Modern researches have shown that there is an inti- 
mate connection between many other affections and albuminuria ; as, 
for example, certain forms of paralysis, either of special nerves, as 
puerperal amaurosis, or of the spinal system ; cephalalgia and dizzi- 
ness; puerperal mania ; and possibly hemorrhage. It cannot, there- 
fore, be doubted that albuminuria in the pregnant woman is liable, at 
any rate, to be associated with grave disease, although the present state 
of our knowledge does not enable us to define very distinctly its pre- 
cise mode of action. 

The presence of albumin in the urine of pregnant women is far 
from a rare phenomenon. Blot and Litzman met with albuminuria 
in 20 per cent, of pregnant women, which is, however, far above the 
estimate of other authors ; Fordyce Barker l thinks it occurs in about 
one out of 25 cases, or 4 per cent. ; Hofmeier 2 found it in 137 out 
of 5000 deliveries in the Berlin Gynecological Institution, or 2.74 
per cent. ; while, more recently, Leopold Meyer 3 found it in 5.4 per 
cent, out of 1124 cases, with casts in 2 per cent. As in most of these 
cases it rapidly disappears after delivery, it is obvious that its presence 
must, in a large proportion of cases, depend on temporary causes, and 
has not always the same serious importance as in the non-pregnant 
state. This is further proved by the undoubted fact that albumin, 
rapidly disappearing after delivery, is often found in the urine of 
pregnant women who go to term, and pass through labor without any 
unfavorable symptoms. 

Pressure by the Gravid Uterus. — The obvious facts that in 
pregnancy the vessels supplying the kidneys are subjected to mechan- 
ical pressure from the gravid uterus, and that congestion of the venous 
circulation of those viscera must necessarily exist to a greater or less 
degree, suggest that here we may find an explanation of the frequent 
occurrence of albuminuria. This view is further strengthened by the 
fact that the albumin rarely appears until after the fifth month, and, 
therefore, not until the uterus has attained a considerable size ; and 
also that it is comparatively more frequently met with in primiparse, 
in whom the resistance of the abdominal parietes, and consequent 
pressure, must be greater than in women who have already borne 
children. It is, indeed, probable that pressure and consequent venous 
congestion of the kidneys have an important influence in its produc- 
tion ; but there must be, as a rule, some other factors in operation,, 

1 American Journal of Obstetrics, vol. xi. p. 449. 

2 Berlin, klin. Wocnenschr., September, 1878. 

3 Zeitschr. fur Geb. u. Gyn., Band xvi. S. 215. 



DISEASES OF PREGNANCY. 213 

since an equal or even greater amount of pressure is often exerted by 
ovarian and fibroid tumors, without any such consequences. They are 
probably complex. One important condition is doubtless the increased 
amount of work the kidneys have to do in excreting the waste prod- 
ucts of the foetus, as well as those of the mother. The increased 
arterial tension throughout the body associated with hypertrophy of 
the heart, known to exist in pregnancy, also operates in the same 
direction. But in the large majority of cases, although these condi- 
tions are present, no albuminuria exists, and they must, therefore, be 
looked upon as predisposing causes, to which some other is added 
before the albumin escapes from the vessels. What this is generally 
escapes our observation, but probably any condition producing sudden 
hyperemia of the kidneys, and giving rise to a state analogous to the 
first stage of Bright' s disease — such, for example, as sudden exposure 
to cold and impeded cutaneous action — may be sufficient to set a light 
to the match already prepared by the existence of pregnancy. 

Toxaemia. — Clifford Allbutt 1 has recently published a suggestive 
paper on this subject, in which he argues against the mechanical causa- 
tion of the albuminuria of pregnancy, and refers it to the presence in 
the blood of some toxic material, absorbed from the intestinal tract, 
which in ordinary conditions would be eliminated without mischief by 
the action of the liver, which in certain pregnancies fails to carry out 
its protective functions. He also refers other diseases of pregnancy, 
such as excessive vomiting, cardiac disease, etc., to similar causes. 
This theory calls for careful investigation, but it is not based on any 
definite facts, and certainly canuot be taken as proved. 

It has been pointed out that a transient albuminuria, disappear- 
ing in a few days, is very common during and after labor, and 
probably depends on a catarrhal condition of the urinary tract. 
Ingersten 2 observed this in 50 out of 153 deliveries, and in 15 only 
had any albumin existed before the confinement ; and Meyer 3 in 25 
per cent, out of 11,138 women in labor, with casts in 12 per cent. 
In addition to these temporary causes it must not be forgotten that 
pregnancy may supervene in a patient already suffering from Bright's 
disease, when, of course, the albumin will exist in the urine from the 
commencement of gestation. 

The various diseases associated with the presence of albumin in the 
urine will require separate consideration. Some of these, especially 
puerperal eclampsia, are amongst the most dangerous complications of 
pregnancy. Others, such as paralysis, cephalalgia, dizziness, may also 
be of considerable gravity. The precise mode of their production, 
and whether they can be traced, as is generally believed, to the reten- 
tion of urinary elements in the blood, either urea or free carbonate of 
ammonia produced by its decomposition, or whether the two are only 
common results of some undetermined cause, will be considered when 
we come to discuss puerperal convulsions. Whatever view may ulti- 
mately be taken on these points, it is sufficiently obvious that albu- 
minuria in a pregnant woman must constantly be a source of much 

' Lancet, Feb. 27, 1897. 

2 Zeitschrift f. Geburt. u. Gyniik., Band v. Heft 2. 3 Op. cit. 



214 PREGNANCY. 

anxiety, and must induce us to look forward with considerable appre- 
hension to the termination of the case. 

Prognosis. — We are scarcely in possession of a sufficiently large 
number of observations to justify any very accurate conclusions as to 
the risk attending albuminuria during pregnancy, but it is certainly 
by no means slight. Hofmeier believes that albuminuria is a most 
severe complication both for woman and child, even when uncompli- 
cated with eclampsia. The prognosis, he thinks, depends on whether 
it is acute in its onset, that is, coming on within a few days of labor, 
or is extended over several weeks. The former is more likely to pass 
entirely away after delivery, while in the latter there is more risk of 
the morbid state of the kidneys becoming permanent, and leading to 
the establishment of Bright's disease after the pregnancy is over. 
Goubeyre estimated that 49 per cent, of primiparse who have albu- 
minuria, and who escape eclampsia, die from morbid conditions trace- 
able to the albuminuria. This conclusion is probably much exagger- 
ated, but, if it even approximate to the truth, the danger must be very 
great. 

Besides the ultimate risk to the mother, albuminuria strongly pre- 
disposes to abortion, no doubt on account of the imperfect nutrition of 
the foetus by blood impoverished by the drain of albuminous materials 
through the kidneys. This fact has been observed by many writers. 
A good illustration of it is given by Tanner, 1 who states that four out 
of seven women he attended suffering from Bright' s disease during 
pregnancy, aborted, one of them three times in succession. There is 
also a strong tendency to intra-uterine death of the child, especially in 
the acute cases coming on shortly before delivery accompanied by 
eclampsia. 

Symptoms. — The symptoms accompanying albuminuria in preg- 
nancy are by no means uniform or constantly present. That which 
most frequently causes suspicion is anasarca — not only the cedematous 
swelling of the lower limbs which is so common a consequence of the 
pressure of the gravid uterus, but also of the face and upper extremi- 
ties. Any puffiness or infiltration about the face, or any oedema about 
the hands or arms, should always give rise to suspicion, and lead to a 
careful examination of the urine. Sometimes this is carried to an 
exaggerated degree, so that there is anasarca of the whole body. 

Anomalous nervous symptoms — such as headache, transient dizzi- 
ness, dimness of vision, spots before the eyes, inability to see objects 
distinctly, sickness in women not at other times suffering from nausea, 
sleeplessness, irritability of temper — are also often met with, some- 
times to a slight degree, at others very strongly developed, and should 
always arouse suspicion. Indeed, knowing as we do that many morbid 
states may be associated with albuminuria, we should make a point of 
carefully examining the urine of all patients in whom any unusually 
morbid phenomena show themselves during pregnancy. 

The condition of the urine varies considerably, but it is generally 
scanty and highly colored, and, in addition to the albumin, especially 

1 Signs and Diseases of Pregnancy, p. 428. 



DISEASES OF PREGNANCY. 215 

in cases in which the albuminuria has existed for some time, we may 
find epithelium cells, tube-casts, and occasionally blood corpuscles. 

Treatment. — The treatment must be based on what has been said 
as to the causes of the albuminuria. Of course, it is out of our power 
to remove the pressure of the gravid uterus, except by inducing labor ; 
but its effects may at least be lessened by remedies tending to promote 
an increased secretion of urine, and thus diminishing the congestion 
of the renal vessels. The administration of saline diuretics, such as 
the acetate of potash, or bitartrate of potash, the latter being given 
in the form of the well-known imperial drink, will best answer this 
indication. The action of the bowels may be excited by purgatives 
producing watery motions, such as occasional doses of compound jalap 
powder. Dry cupping over the loins, frequently repeated, has a bene- 
ficial effect in lessening the renal hyperemia. The action of the skin 
should also be promoted by the use of the vapor bath, and with this 
view the Turkish bath may be employed with great benefit and perfect 
safety. Jaborandi and pilocarpin have been given for this purpose, 
but have been found by Fordyce Barker to produce a dangerous degree 
of depression. The next indication is to improve the condition of the 
blood by appropriate diet and medication. A very light and easily 
assimilated diet should be ordered, of which milk should form the 
staple. Tarnier 1 has recorded several cases in which a purely milk 
diet was very successful in removing albuminuria. With the milk, 
which should be skimmed, we may allow white of egg, or a little white 
fish. The tincture of the perchloride of iron is the best medicine we 
can give, and it may be advantageously combined with small doses of 
tincture of digitalis, which acts as an excellent diuretic. 

Finally, in obstinate cases we shall have to consider the advisability 
of inducing premature labor. The propriety of this procedure in the 
albuminuria of pregnancy has of late years been much discussed. 
Spiegelberg 2 is opposed to it, while Barker 3 thinks it should only be 
resorted to " when treatment has been thoroughly and perseveringly 
tried without success for the removal of symptoms of so grave a char- 
acter that their continuance would result in the death of the patient." 
Hofmeier,' on the other hand, is in favor of the operation, which he 
does not think increases the risk of eclampsia, and may avert it 
altogether. I believe that, having in view the undoubted risks which 
attend this complication, the operation is unquestionably indicated, 
and is perfectly justifiable, in all cases attended with symptoms of 
serious gravity. It is not easy to lay down any definite rules to guide 
our decision ; but I should not hesitate to adopt this resource in all 
cases in which the quantity of albumin is considerable and progressively 
increasing, and in which treatment lias failed to lessen the amount; 
and, above all, in every case attended with threatening symptoms, 
such as severe headache, dizziness, or loss of sight. The risks of the 
operation are infinitesimal compared with those which the patient 
would run in the event of puerperal convulsions supervening, or 
chronic Bright's disease becoming established. As the operation is 

1 Anual. de Gynec. torn. v. p. 41. 2 Lehrbuch der Geburt. 

3 Amer. Journ. of Obstet., vol. xi. p. 449. * Op. cit. 



216 



PKEGNANCY. 



seldom likely to be indicated until the child has reached a viable age, 
and as the albuminuria places the child's life in danger, we are quite 
justified in considering the mother's safety alone in determining on its 
performance. 

Diabetes. — The occurrence of pregnancy in a woman suffering from 
diabetes may lead to serious consequences, and has recently been 
specially investigated by Dr. Matthews Duncan. 1 This must be 
carefully distinguished from the physiological glycosuria commonly 
present at the end of pregnancy, and during lactation. It is probable 
that diabetic patients are inapt to conceive, but when pregnancy does 
occur under such conditions, the case cannot be considered devoid of 
anxiety. From the cases collected by Dr. Duncan it would appear 
that pregnancy is very liable to be interrupted in its course, generally 
by the death of the foetus, which has very often occurred. In some 
instances no bad results have been observed, while in others the 
patient has collapsed after delivery. Diabetic coma does not seem to 
have been observed. Out of twenty-two pregnancies in diabetic 
women four ended fatally, so that the mortality is obviously very 
large. Too little is known on this subject to justify positive rules of 
treatment ; but if the symptoms are serious and increasing, it would 
probably be justifiable to induce labor prematurely, so as to lessen the 
strain to which the patient's constitution is subjected. 



CHAPTEE VIII. 

DISEASES OF PREGNANCY— Continued. 

Disorders of the Nervous System. — There are many disorders of 
the nervous system met with during the course of pregnancy. Among 
the most common are morbid irritability of temper, or a state of mental 
despondency and dread of the results of the labor, sometimes almost 
amounting to insanity, or even progressing to actual mania. These 
are but exaggerations of the highly susceptible state of the nervous 
system generally associated with gestation. Want of sleep is not 
uncommon, and, if carried to any great extent, may cause serious 
trouble from the irritability and exhaustion it produces. In such 
cases we should endeavor to lessen the excitable state of the nerves, 
by insisting on the avoidance of late hours, overmuch society, exciting 
amusements, and the like ; while it may be essential to promote sleep 
by the administration of sedatives, none answering so well as the 
chloral hydrate, in combination with large doses of bromide of potas- 
sium or sodium, which greatly intensify its hypnotic effects. 

1 Obst. Trans., vol. xxiv. p. 256. 



DISEASES OF PREGNANCY. 217 

Severe headaches and various intense neuralgise are common. 
Amongst the latter the most frequently met with are pain in the 
breasts, due to the intimate sympathetic connection of the mammae 
with the gravid uterus ; and intense intercostal neuralgia, which a 
careless observer might mistake for pleuritic or inflammatory pain. 
The thermometer, by showing that there is no elevation of tempera- 
ture, would prevent such a mistake. Neuralgia of the uterus itself, 
or severe pains in the groins or thighs — the latter being probably the 
mechanical results of draggino; on the attachments of the abdominal 

CO © 

muscles — are also far from uncommon. In the treatment of such 
neuralgic affections attention to the state of the general health, and 
quinine, arsenic or iron preparations whenever there is much debility, 
will be indicated. Locally sedative applications, such as belladonna 
and chloroform liniments ; friction with aconite ointment when the 
pain is limited to a small space; and, in the worst cases, the subcuta- 
neous injection of morphia, will be called for. Those pains which ap- 
parently depend on mechanical causes may often be best relieved by 
lessening the traction on the. muscles, by wearing a well-made elastic 
belt to support the uterus. 

Paralysis. — Among the most interesting of the nervous diseases are 
various paralytic affections. Almost all varieties of paralysis have 
been observed, such as paraplegia, hemiplegia (complete or incomplete) 
facial paralysis, and paralysis of the nerves of special sense, giving 
rise to amaurosis, deafness, and loss of taste. Churchill records 
twenty-two cases of paralysis during pregnancy, collected by him from 
various sources. A large number have also been brought together by 
Imbert Goubeyre, in an interesting memoir on the subject, and others 
are recorded by Fordyce Barker, Joulin, and other authors ; so that 
there can be no doubt of the fact that paralytic affections are common 
during gestation. In a large proportion of the cases recorded the 
paralyses have been associated with albuminuria, and are doubtless 
ursemic in origin. Thus in nineteen cases, related by Goubeyre, albu- 
minuria was present in all ; Darcy, 1 however, found no albuminuria in 
five out of fourteen cases. The dependency of the paralysis on a transient 
cause explains the fact that in a large majority of these cases it was 
not permanent, but disappeared shortly after labor. In every case of 
paralysis, whatever be its nature, special attention should be directed 
to the state of the urine, and, should it be found to be albuminous, 
labor should be at once induced. This is clearly the proper course to 
pursue, and we should certainly not be justified in running the risk 
that must attend the progress of a case in which so formidable a 
symptom has already developed itself. When the cause has been 
removed, the effect will also generally rapidly disappear, and the 
prognosis is therefore, on the whole, favorable. Should the paralysis 
continue after delivery, the treatment must be such as we would adopt 
in the non-pregnant state ; and small doses of strychnia, along with 
faradization of the affected limbs, would be the best remedies at our 
disposal. 

i These de Paris, 1877- 



218 PREGNANCY. 

There are, however, unquestionably some cases of puerperal paralysis 
which are not uremic in their origin, and the nature of which is some- 
what obscure. Hemiplegia may doubtless be occasioned by cerebral 
hemorrhage, as in the non-pregnant state. Other organic causes of 
paralysis, such as cerebral congestion, or embolism, may, now and 
again, be met with during pregnancy, but cases of this kind must be 
of comparative rarity. Other cases are functional in their origin. 
Tarnier relates a case of hemiplegia which he could only refer to 
extreme anaemia. Some, again, may be hysterical. Paraplegia is 
apparently more frequently unconnected with albuminuria than the 
other forms of paralysis ; and it may either depend on pressure of the 
gravid uterus on the nerves as they pass through the pelvis, or on 
reflex action, as is sometimes observed in connection with uterine 
disease. When, in such cases, the absence of albuminuria is ascer- 
tained by frequent examination of the urine, there is obviously not the 
same risk to the patient as in cases depending on uraemia, and, there- 
fore, it may be justifiable to allow pregnancy to go on to term, trusting 
to subsequent general treatment to remove the paralytic symptoms. 
As the loss of power here depends on a transient cause, a favorable 
prognosis is quite justifiable. Partial paralysis of one lower extremity, 
generally the left, sometimes occurs, from pressure of the foetal occiput, 
and may continue for days, or weeks, with a gradual improvement, 
after parturition. 

Chorea. — Chorea is not infrequently observed, and forms a serious 
complication. It is generally met with in young women of delicate 
health, and in the first pregnancy. In a large proportion of the cases 
the patient has already suffered from the disease before marriage. In 
the occurrence of pregnancy, the disposition of the disease again be- 
comes evoked, and choreic movements are re-established. This fact 
may be explained partly by the susceptible state of the nervous system, 
partly by the impoverished condition of the blood. 

Prognosis. — That chorea is a dangerous complication of pregnancy 
is apparent by the fact that out of 255 cases collected by Buist 1 no less 
than forty-five, or one in five, proved fatal. Nor is it danger to life 
alone that is to be feared, for it appears certain that chorea is more apt 
to leave permanent mental disturbance when it occurs during preg- 
nancy than at other times. It has also an unquestionable tendency to 
bring on abortion or premature labor, and in many cases the life of the 
child is sacrified. 

Treatment. — The treatment of chorea during pregnancy does not 
differ from that of the disease under more ordinary circumstances ; and 
our chief reliance will be placed on such drugs as the liquor arsenicalis, 
bromide of potassium, and iron. In the severe form of the disease, 
the incessant movements, and the weariness and loss of sleep, may very 
seriously imperil the life of the patient, and more prompt and radical 
measures will be indicated. If, in spite of our remedies, the paroxysms 
go on increasing in severity, and the patient's strength appears to be 
exhausted, our only resource is to remove the most evident cause by 

i Edin. Obst. Trans., vol. xx. p. 145. 



DISEASES OF PREGNANCY. 219 

inducing labor. Generally the symptoms lessen and disappear soon 
after this is done. There can be no question that the operation is per- 
fectly justifiable, and may even be essential under such circumstances. 
It should be borne in mind that the chorea often recurs in a subsequent 
pregnancy, and extra care should then always be taken to prevent its 
development. 

Tetanus. — Tetanus has not infrequently been observed in connec- 
tion with pregnancy in the tropics, where the disease is common. In 
temperate climates it is exceedingly rare, and has been more often met 
with after abortion than after labor at term. Receut researches have 
clearly connected this disease with a specific bacillus, chiefly contained 
in earth, which in puerperal cases probably finds its entrance through 
lesions of continuity in the genital tract. Its prevention, therefore, 
must obviously depend to a great extent on such personal cleanliness 
as will avoid contamination. The risk to the patient is very great. 
Out of thirty cases recorded, twenty-eight by Simpson, two by Wilt- 
shire, only six recovered; and Gautier 1 found that the mortality was 
86 per cent. It is only needful to refer here to the very satisfactory 
results that have followed the use of antitoxic serum in the treatment 
of tetanus, which would uow always be tried. 

There is a comparatively mild form of muscular contraction, chiefly 
limited to the hands or feet, known as tetany, which might possibly be 
mistaken for true tetanus. Trousseau, who was the first to describe 
it, called it " contracture des nourrices," from the fact of its being fre- 
quently found in nursing women. It is not a common affection, and 
I have myself never seen a case. It is probably always connected 
with causes producing general weakness, and should be dealt with by 
a course of tonic treatment. 

Disorders of the Urinary Organs. Retention of Urine. — Dis- 
orders of the urinary organs are of frequent occurrence. Retention of 
urine may be met with, and this is often the result of a retroverted 
uterus. The treatment, therefore, must then be directed to the removal 
of the cause. This subject will be more particularly considered when 
we come to discuss that form of displacement (p. 224) ; but we may 
here point out that reteution of urine, if long continued, may not only 
lead to much distress, but to actual disease of the coats of the bladder. 
Several cases have been recorded in which cystitis, resulting from 
urinary retention in pregnancy, eventually caused the exfoliation of 
the entire mucous membrane of the bladder, 2 which was cast off, some- 
times entire, sometimes in shreds, and occasionally with portions of the 
muscular coat attached to it. The possibility of this formidable accident 
should teach us to be careful not to allow any undue retention of urine, 
but, by a timely use of the catheter, to relieve the symptoms, while 
we, at the same time, endeavor to remove the cause. 

Irritability of the bladder is of frequent occurrence. In the early 
months it seems to be the consequence of sympathetic irritation of the 
neck of the bladder, combined with pressure, while in the later months 
it is, probably, solely produced by mechanical causes. When severe 

» Rev. med. de la Swisse Xormande. 1889. * Obst. Trans., vol. iv. p. 13. 



220 PREGNANCY. 

it leads to much distress, the patient's rest being broken and disturbed 
by incessant calls to micturate, and the suffering induced may produce 
serious constitutional disturbances. I have elsewhere pointed out 1 that 
irritability of the bladder in the later months of pregnancy is frequently 
associated with an abnormal position of the foetus, which is placed 
transversely or obliquely. The result is either that undue pressure is 
applied to the bladder, or that it is drawn out of its proper position. 
The abnormal position of the foetus can be easily detected by palpation, 
and is readily altered by external manipulation. In some of the cases 
I have recorded, altering the position of the foetus was immediately 
followed by relief; the symptoms recurring after a time, when the 
foetus had again assumed an oblique position. Should the foetus fre- 
quently become displaced, an endeavor may be made to retain it in the 
longitudinal axis of the uterus by a proper adaptation of bandages and 
pads. In cases not referable to this cause we should attempt to relieve 
the bladder symptoms by appropriate medication, such as small doses 
of liquor potassae, if the urine be very acid ; tincture of belladonna j 
the decoction of triticum repens, an old but very serviceable remedy ; 
and vaginal sedative pessaries containing morphia or atropine. 

Women who have borne many children are often troubled with 
incontinence of urine during pregnancy, the water dribbling away on 
the slightest movement. Through this much irritation of the skin 
surrounding the genitals is produced, attended with troublesome exco- 
riations and eruptions. Relief may be partially obtained by lessening 
the pressure on the bladder by an abdominal belt, while the skin is 
protected by applications of simple ointment or vaseline. 

Dr. Tyler Smith has directed attention to a phosphatic condition of 
the urine occurring in delicate women, whose constitutions are severely 
tried by gestation. This condition can easily be altered by rest, nutri- 
tious diet, and a course of restorative medicine, such as steel, mineral 
acids, and the like. 

Leucorrhcea. — A profuse, whitish, leucorrhoeal discharge is very 
common during pregnancy, especially in its latter half. The discharge 
frequently alarms the patient, but, unless it is attended with disagree- 
able symptoms, it does not call for special treatment. When at all 
excessive, it may lead to much irritation of the vagina and external 
generative organs. The labia may become excoriated and covered with 
small aphthous patches, and the whole vulva may be hot, swollen, and 
tender. Warty growths, similar in appearance to syphilitic condylo- 
mata, are occasionally developed in pregnant women, unconnected with 
any specific taint, and associated with the presence of an irritating 
leucorrhoeal discharge. According to Thibierge, 2 these resist local 
applications, such as sulphate of copper or nitrate of silver, but spon- 
taneously disappear after delivery. Inasmuch as the leucorrhoeal 
discharge is dependent on the congested condition of the generative 
organs accompanying pregnancy, we can hope to do little more than 
alleviate it. In the severer forms, as has been pointed out by Henry 
Bennet, the cervix will be found to be abraded or covered with granular 

i Ibid., vol. xiii. p. 42. 2 Arch. gen. de Med., 1856. 



DISEASES OF PREGNANCY. 221 

erosion, and it may be, from time to time, cautiously touched with the 
nitrate of silver or a solution of carbolic acid. Generally speaking, 
we must content ourselves with recommending the patient to wash the 
vagina out gently with diluted Condy's fluid ; or with a solution of 
the sulpho-carbolate of zinc, of the strength of four grains to the 
ounce of water ; or with plain tepid water. For obvious reasons fre- 
quent and strong vaginal douches are to be avoided, but a daily gentle 
injection, for the purpose of ablution, can do no harm. 

Pruritus. — A very distressing pruritus of the vulva is frequently 
met with along with leucorrhoea, especially when the discharge is of 
an acrid character, which in some cases leads to intense and protracted 
suffering, forcing the patient to resort to incessant friction of the parts. 
Pruritus, however, may exist without leucorrhoea, being apparently 
sometimes of a neuralgic character, at others associated with aphthous 
patches on the mucous membrane, ascarides in the rectum, or pediculi 
in the hairs of the mons Veneris and labia. Cases are even recorded 
in which the pruritic irritation extended over the whole body. The 
treatment is difficult and unsatisfactory. Various sedative applications 
may be tried, such as weak solutions of Goulard's lotion ; or a lotion 
composed of an ounce of the solution of the muriate of morphia, with 
a drachm and a half of hydrocyanic acid, in six ounces of water; or 
one formed by mixing one part of chloroform with six of almond oil. 
A very useful form of medication consists in the insertion into the 
vagina of a pledget of cotton-wool, soaked in equal parts of the 
glycerin of borax and sulphurous acid ; this may be inserted at bed- 
time, and withdrawn in the morning by means of a string attached to 
it. Smearing the parts with an ointment consisting of boracic acid 
and vaseline often answers admirably. Kelief is also sometimes 
afforded by ichthyol ointment. In the more obstinate cases, the solid 
nitrate of silver may be lightly brushed over the vulva ; or, as recom- 
mended by Tarnier, a solution of bichloride of mercury, of about the 
strength of two grains to the ounce, may be applied night and morning. 
The state of the digestive organs should always be attended to, and 
aperient mineral water may be usefully administered. AVhen the pru- 
ritus extends beyond the vulva, or even in severe local cases, large 
doses of bromide of potassium may perhaps be useful in lessening the 
general hypersesthetic state of the nerves. 

CBdema of the Lower Limbs. — Some of the disorders of preg- 
nancy are the direct results of the mechanical pressure of the gravid 
uterus. The most common of these are cedema and a varicose state of 
the veins of the lower extremities, or even of the vulva. The former 
is of little consequence, provided we have assured ourselves that it is 
really the result of pressure, and not of albuminuria, and it can gener- 
ally be relieved by rest in the horizontal position. A varicose state of 
the veins of the lower limbs is very common, especially in multipara, 
in whom it is apt to continue after delivery. The varicosity is gener- 
ally limited to the superficial veins, chiefly the saphena, and the veins 
on the inner surface of the leg and thigh ; sometimes the deeper veins 
are also affected, and this is said to be accompanied by severe pain in 
the sole of the foot when the patient is standing or walking. Occa- 



222 PREGNANCY. 

sionally the veins of the vulva, and even of the vagina, are also 
enlarged and varicose, producing considerable swelling of the external 
genitals. Rest in the recumbent position and the use of an abdominal 
belt, so as to take the pressure off the veins as much as possible, are 
all that can be done to relieve this troublesome complication. If the 
veins of the legs are much swollen some benefit may be derived from 
an elastic stocking or a carefully applied bandage. 

Laceration of the Veins. — Serious and even fatal consequences 
have followed the accidental laceration of the swollen veins. When 
laceration occurs during or immediately after delivery — a not uncom- 
mon result of the pressure of the head — it gives rise to the formation 
of a vaginal thrombus. It has occasionally happened from an acci- 
dental injury during pregnancy, as in the cases recorded by Simpson, 
in which death followed a kick on the pudenda, producing laceration 
of a varicose vein, or in one mentioned by Tarnier, where the patient 
fell on the edge of a chair. Severe hemorrhage has followed the acci- 
dental rupture of a vein in the leg. The only satisfactory treatment 
is pressure, applied directly to the bleeding parts by means of the 
finger, or by compresses saturated in a solution of the perchloride of 
iron. The treatment of vaginal thrombus following labor must be 
considered elsewhere. Occasionally the varicose veins inflame, become 
very tender and painful, and coagula form in their canals. In such 
cases absolute rest should be insisted on, while sedative lotions, such as 
the chloroform and belladonna liniments, should be applied to relieve 
the pain. 

Displacements of the Gravid Uterus. — Certain displacements of 
the gravid uterus are met with which may give rise to symptoms of 
great gravity. 

Prolapse, which is rare, is almost always the result of pregnancy 
occurring in a uterus which had been previously more or less procident. 
Under such circumstances the increasing weight of the uterus will at 
first necessarily augment the previously existing tendency to prolapse 
of the womb, which may come to protrude partially and entirely 
beyond the vulva. In the great majority of cases, as pregnancy 
advances, the prolapse cures itself, for at about the fourth or fifth 
month the uterus will rise above the pelvic brim. It has been said 
that in some cases of complete procidentia pregnancy has gone even 
to term, with the uterus lying entirely outside the vulva. Most prob- 
ably these cases were imperfectly observed, the greater part of the 
uterus being in reality above the pelvic brim, a portion only of its 
lower segment protruding externally ; or, as has sometimes been the 
case, the protruding portion has been an old-standing hypertrophic 
elongation of the cervix, the internal os uteri and fundus being nor- 
mally situated. Should a prolapsed uterus not rise into the abdominal 
cavity as pregnancy advances, serious symptoms will be apt to develop 
themselves ; for, unless the pelvis be unusually capacious, the enlarging 
uterus will get jammed within its bony walls, the rectum and urethra 
will be pressed upon, defecation and micturition will be consequently 
impeded, and severe pain and much irritation will result. In all prob- 
ability such a state of things would lead to abortion. The possibility 



DISEASES OF PREGNANCY. 223 

of these consequences should, therefore, teach us to be careful in the 
management of every case of prolapse, however slight, in which preg- 
nancy occurs. Absolute rest, in the horizontal position, should be 
insisted on ; while the uterus should be supported in the pelvis by a 
full-sized Hodge's pessary, which should be worn until at least the 
sixth month, when the uterus would be fully within the abdominal 
cavity. After delivery, prolonged rest should be recommended, in the 
hope that the process of involution may be accompanied by a cure of 
the prolapse. There can be no doubt that pregnancy carried to term 
affords an opportunity of curing even old-standing displacements which 
should not be neglected. 

Anteversion of the gravid uterus seldom produces symptoms of 
consequence. In all probability it is common enough Avheu pregnancy 
occurs in a uterus which is more than usually anteverted, or is ante- 
flexed. Under such circumstances, there is not the same risk of incar- 
ceration in the pelvic cavity as in cases in which pregnancy exists in a 
retronexed uterus; for, as the uterus increases in size, it rises without 
difficulty into the abdominal cavity. In the early months the pressure 
of the fundus on the bladder may account for the irritability of that 
viscus then so commonly observed. It will be remembered that Graily 
Hewitt attributes great importance to this condition as explaining the 
sickness of pregnancy — a theory, however, which has not met with 
general acceptation. 

Extreme anteversion of the uterus, at an advanced period of preg- 
nancy, is sometimes observed in multiparas with very lax abdominal 
walls, occasionally to such an extent that the uterus falls completely 
forward and downward, so that the fundus is almost on a level with 
the patient's knees. This form of pendulous belly may be associated 
with a separation of the recti muscles, between which the womb forms 
a ventral hernia, covered only by the cutaneous textures. When labor 
comes on, this variety of displacement may give rise to trouble by 
destroying the proper relation of the uterine and pelvic axes. The 
treatment is purely mechanical, keeping the patient lying on her back 
as much as possible, and supporting the pendulous abdomen by a prop- 
erly adjusted bandage. A similar forward displacement is observed 
in cases of pelvic deformity, and in the worst forms, in rhachitic and 
dwarfed women, it exists to a very exaggerated degree. 

Retroversion. — The most important of the displacements, in con- 
sequence of its occasional very serious results, is retroversion of the 
gravid uterus. It was formerly generally believed that this was most 
commonlv produced by some accident, such as a fall, which dislocated 
a uterus previously in a normal position. Undue distention of the 
bladder was also considered to have an important influence in its pro- 
duction, by pressing the uterus backward and downward. 

Causes. — It is now almost universally admitted that, although the 
above-named causes may possibly sometimes produce it, in the very 
large proportion of cases it depends on pregnancy having occurred in 
a uterus previously retroverted or retronexed. The merit of pointing 
out this fact unquestionably belongs to the late Dr. Tyler Smith, and 
further observations have fully corroborated the correctness of his 
views. 



224 PREGNANCY. 

In the large majority of cases in which pregnancy occurs in a uterus 
so displaced, as the womb enlarges it straightens itself, and rises into 
the abdominal cavity, without giving any particular trouble ; or, as 
not unfrequently happens, the abnormal position of the organ inter- 
feres so much with its enlargement as to produce abortion. Sometimes, 
however, the uterus increases without leaving the pelvis until the third 
or fourth month, when it can no longer be retained in the pelvic cavity 
without inconvenience. It then presses on the urethra and rectum, 
and eventually becomes completely incarcerated within the rigid walls 
of the bony pelvis, giving rise to characteristic symptoms. 

Symptoms. — The first sign which attracts attention is generally 
some trouble connected with micturition, in consequence of pressure on 
the urethra. On examination the bladder will often be found to be 
enormously distended, forming a large, fluctuating abdominal tumor, 
which the patient has lost all power of emptying. Frequently small 
quantities of urine dribble away, leading the woman to believe that 
she has passed water, and thus the distention is often overlooked. 
Sometimes the obstruction to the discharge of urine is so great as to 
lead to dropsical effusion into the cellular tissue of the arms and legs. 
This was very well marked in one of my cases, and disappeared rapidly 
after the bladder had been emptied. Difficulty in defecation, tenesmus, 
obstinate constipation, and inability to empty the bowels, become estab- 
lished about the same time. These symptoms increase, accompanied by 
some pelvic pain, and a sense of weight and bearing down, until at last 
the patient applies for advice, and the true nature of the case is detected. 
When the retroversion occurs suddenly, all these symptoms develop 
with great rapidity, and are sometimes very serious from the first. 

Progress and Termination. — The further progress is various. 
Sometimes, after the uterus has been incarcerated in the pelvis for 
more or less time, it may spontaneously rise into the abdominal cavity, 
when all threatening symptoms will disappear. So happy a termina- 
tion is quite exceptional, and should the practitioner not interfere and 
effect reposition of the organ, serious and even fatal consequences may 
ensue, unless abortion occurs. 

The extreme distention of the bladder, and the impossibility of 
relieving it, may lead to lacerations of its coats and fatal peritonitis ; 
or the retention of urine may produce cystitis, with exfoliation of the 
coats of the bladder ; or, as more commonly happens, retention of 
urinary elements may take place, and death occur with all the symp- 
toms of ursemic poisoning. At other times the impacted uterus 
becomes congested and inflamed, and eventually sloughs, its contents, 
if the patient survive, being discharged by fistulous communications 
into the rectum and vagina. It need hardly be said that such termi- 
nations are only possible in cases which have been grossly mismanaged, 
or the nature of which has not been detected till a late period. 

Diagnosis. — The diagnosis is not difficult. On making a vaginal 
examination, the finger impinges on a smooth round elastic swelling, 
filling up the lower part of the pelvis, stretching and depressing the 
posterior vaginal wall, which occasionally protrudes beyond the vulva. 
On passing the finger forward and upward we shall generally be able 



DISEASES OF PREGNANCY. 225 

to reach the cervix, high up behind the pubes, and pressing on the 
urethral canal. In very complete retroversion it may be difficult or 
impossible to reach the cervix at all. On abdominal examination the 
fundus uteri cannot be felt above the pelvic brim ; this, as the retro- 
version does not give rise to serious symptoms until between the third 
and fourth months, should, under natural circumstances, always be 
possible. By bimanual examination we can make out, with due care, 
the alternate relaxation and contraction of the uterine parietes char- 
acteristic of the gravid uterus, and so differentiate the swelling from 
any other in the same situation. The accompanying phenomena of 
pregnancy will also prevent any mistake of this kind. 

In some few cases retroversion has been supposed to go on to term. 
Strictly speaking, this is impossible ; but in the supposed examples, 
such as the well-known case recorded by Oldham, part of a retroflexed 
uterus remained in the pelvic cavity, while the greater part developed 
in the abdominal cavity. The uterus is, therefore, divided, as it were, 
into two portions : one, which is the flexed fundus, remaining in the 
pelvis, the other, containing the greater part of the foetus, rising above 
it. Under these circumstances, a tumor in the vagina would exist in 
combination with an abdominal tumor, and pregnancy might go on to 
term. Considerable difficulty may even arise in labor, but the mal- 
position generally rectifies itself before it gives rise to any serious 
results. 

Treatment. — The treatment of retroversion of the gravid uterus 
should be taken in hand as soon as possible, for every day's delay 
involves an increase in the size of the uterus, and leads, therefore, to 
greater difficulty in reposition. Our object is to restore the natural 
direction of the uterus, by lifting the fundus above the promontory 
of the sacrum. The first thing to be done is to relieve the patient by 
emptying the bladder, the retention of urine having probably originally 
called attention to the case. For this purpose it is essential to use a 
long elastic male catheter of small size, as the urethra is too elongated 
and compressed to admit of the passage of the ordinary silver instru- 
ment. Even then it may be extremely difficult to introduce the 
catheter, and sometimes it has been found to be quite impossible. 
Under such circumstances, provided reposition cannot be effected 
without it, the bladder may be punctured an inch or two above the 
pubes by means of the fine needle of an aspirator, and the urine drawn 
off. Dieulafoy's work on aspiration proves conclusively that this may 
be done without risk, and the operation has been successfully performed 
by Schatz and others. It very rarely happens, however, and in long- 
neglected cases only, that the withdrawal of the urine is found to be 
impossible. 

The bladder being emptied, and the bowels being also opened, if 
possible, by copious enemata, we proceed to attempt reduction. For 
this purpose various procedures are adopted. If the case is not of very 
long standing, I am inclined to think that the gentlest and safest plan 
is the continuous pressure of a caoutchouc bag, tilled with water, placed 
in the vagina. The good effect of steady and long-continued pressure 
of this kind was proved by Tyler Smith, who effected in this way the 

15 



226 PREGNANCY. 

reduction of an inverted uterus of long standing, and it is not difficult 
to understand that it may succeed when a more sudden and violent 
effort fails. I have tried this plan successfully in several cases, a 
pyriform India-rubber bag being inserted into the vagina and dis- 
tended as far as the patient could bear by means of a syringe. The 
water must be let out occasionally to allow the patient to empty the 
bladder, and the bag immediately refilled. In my cases reposition 
occurred within twenty-four hours. Barnes has failed with this 
method ; but it succeeded so well in my cases, and is so obviously less 
likely to prove hurtful than forcible reposition with the hand, that 
I am inclined to consider it the preferable procedure, and one that 
should be tried first. Failing with the fluid pressure, we should 
endeavor to replace the uterus in the following way. The patient 
should be placed at the edge of the bed, in the ordinary obstetric posi- 
tion, and thoroughly anaesthetized. This is of importance, as it relaxes 
all the parts, and admits of much freer manipulation than is otherwise 
possible. One or more fingers of the left hand are then inserted into 
the rectum ; if the patient be deeply chloroformed, it is quite possible, 
with due care, even to pass the whole hand, and an attempt is then 
made to lift or push the fundus above the promontory of the sacrum. 
At the same time reposition is aided by drawing down the cervix with 
the fingers of the right hand per vaginam. It has been insisted that 
the pressure should be made in the direction of one or other sacro-iliac 
synchondrosis rather than directly upward, so that the uterus may not 
be jammed against the projection of the promontory of the sacrum. 
Failing reposition through the rectum, an attempt may be made per 
vaginam, and for this some have advised the upward pressure of the 
closed fist passed into the canal. Others recommend the hand-and- 
knee position as facilitating reposition, but this prevents the adminis- 
tration of chloroforcn, which is of more assistance than any change of 
position can possibly be. Various complex instruments have been 
invented to facilitate the operation, but they are all more or less 
dangerous, and are unlikely to succeed when manual pressure has failed. 

As soon as the reduction is accomplished, subsequent descent of the 
uterus should be prevented by a large-sized Hodge's pessary, and the 
patient should be kept at rest for some days, the state of the bladder 
and bowels being particularly attended to. When reposition has been 
fairly effected a relapse is unlikely to occur. 

In cases in which reduction is found to be impossible, our only 
resource is the artificial induction of abortion. Under such circum- 
stances this is imperatively called for. It is best effected by puncturing 
the membranes, the discharge of the liquor amnii of itself lessening 
the size of the uterus, and thus diminishing the pressure to which the 
neighboring parts are subjected. After this, reposition may be possible, 
or we may wait until the foetus is spontaneously expelled. It is not 
always easy to reach the os uteri, although we can generally do so with 
a curved uterine sound. If we cannot puncture the membranes, the 
liquor amnii may be drawn off through the uterine walls by means of 
the aspirator, inserted through the vagiua. The injury to the uteriue 
walls thus inflicted is not likely to be hurtful, and the risk is certainly 



DISEASES OF PREGNANCY. 227 

far less than leaving the case alone. Naturally, so extreme a measure 
would not be adopted until all the simpler means indicated have beeu 
tried and failed. 

Diseases Coexisting- "with Pregnancy . — The pregnant woman is, 
of course, liable to contract the same diseases as in the non-pregnant 
state, and pregnancy may occur in women already the subject of some 
constitutional disease. There is no doubt much yet to be learned as 
to the influence of coexisting disease on pregnancy. It is certain that 
some diseases are but little modified by pregnancy, and that others are 
so to a considerable extent ; and that the influence of the disease on 
the foetus varies much. The subject is too extensive to be entered 
into at any length, but a few words may be said as to some of the 
more important affections that are likely to be met with. 

The eruptive fevers have often very serious consequences, propor- 
tionate to the intensity of the attack. Of these variola has the most 
disastrous results, which are related in the writings of the older 
authors, but which are, fortunately, rarely seen in these days of 
vaccination. The severe and confluent forms of the disease are almost 
certainly fatal to both the mother and child. In the discrete form, 
and in modified smallpox after vaccination, the patient generally has 
the disease favorably, and although abortion frequently results, it does 
not necessarily do so. The effects on the children vary. The foetus 
may escape the disease altogether ; or it may be attacked by it either 
before or after birth ; or, if the mother has had smallpox during preg- 
nancy, the child may be subsequently insusceptible to the vaccine virus. 

Scarlet Fever. — If scarlet fever of an intense character attacks a 
pregnant woman, abortion is likely to occur, and the risks to the 
mother are very great. The milder cases run their course without 
the production of any untoward symptoms. Should abortion occur, 
the well-known dangerous effect of this zymotic disease after delivery 
will gravely influence the prognosis. Cazeaux was of opinion that preg- 
nant women are not apt to contract the disease. It has been thought 
that the poison when absorbed during pregnancy might remain latent 
until delivery, when its characteristic effects were produced. It is 
certainly more common after delivery than during pregnancy ; thus 
Olshausen 1 collected one hundred and thirty -five cases of the former 
kind, and only seven of the latter. 

Measles.— Measles, unless very severe, often runs its course without 
seriously affecting the mother or child. I have myself seen several 
examples of this. De Tourcoing, however, states that out of fifteen 
cases the mother aborted in seven, these being all very severe attacks. 
Some cases are recorded in which the child was born with the rubeolous 
eruption upon it. 

Continued Fevers. — The pregnant woman may be attacked with 
any of the continued fevers, and if they are at all severe, they are apt 
toproduce abortion. Out of twenty-two cases of typhoid, sixteen 
aborted, and the remaining six, who had slight attacks, went on to 
term ; out of sixty-three cases of relapsing fever, abortion or premature 

* Arch f. Gynak., Bd. ix. S. 111. 



228 PREGNANCY. 

labor occurred in twenty-three. According to Schweden the main 
cause of danger to the foetus in continued fevers is the hyperpyrexia, 
especially when the maternal temperature reaches 104° or upward. 
The fevers do not appear to be aggravated as regards the mother, and 
the same observation has been made by Cazeaux with regard to this 
class of disease occurring after delivery. 

Pneumonia. — Pneumonia seems to be specially dangerous, for of 
fifteen cases collected by Grisolle 1 eleven died — a mortality immensely 
greater than that of the disease in general. The larger proportion 
also aborted, the children being generally dead, and the fatal result is 
probably due, as in the severe continued fevers, to hyperpyrexia. The 
cause of the maternal mortality does not seem quite apparent, since 
the same danger does not appear to exist in severe bronchitis, or other 
inflammatory affections. 

Phthisis. — Contrary to the usually received opinion, it appears 
certain that pregnancy has no retarding influence on coexisting 
phthisis, nor does the disease necessarily advance with greater rapidity 
after delivery. Out of twenty-seven cases of phthisis, collected by 
Grisolle, twenty-four showed the first symptoms of the disease after 
pregnancy had commenced. Phthisical women are not apt to con- 
ceive; a fact which may probably be explained by the frequent 
coexistence, in such cases, of uterine disease, especially severe leucor- 
rhoea. The entire duration of the phthisis seems to be shortened, as 
it averaged only nine and a half months in the twenty-seven cases 
collected — a fact which proves, at least, that pregnancy has no material 
influence in arresting its progress. If we consider the tax on the vital 
powers which pregnancy naturally involves, we must admit that this 
view is more physiologically probable than the one generally received, 
and apparently adopted without any due grounds. 

Heart Disease. — The evil effects of pregnancy and parturition on 
chronic heart disease have of late received much attention from 
Spiegelberg, Fritsch, Peter, and other writers. The subject has been 
ably discussed 2 in a series of elaborate papers by Dr. Angus Mac- 
donald, which are well worthy of study. Out of twenty-eight cases 
collected by him, seventeen, or 60 per cent., proved fatal. This, no 
doubt, is not altogether a reliable estimate of the probable risk of the 
complication ; but, at any rate, it shows the serious anxiety which the 
occurrence of pregnancy in a patient suffering from chronic heart 
disease must cause. Dr. Macdonald refers the evils resulting from 
pregnancy in connection with cardiac lesions to two causes : first, 
destruction of that equilibrium of the circulation which has been 
established by compensatory arrangements ; secondly, the occurrence 
of fresh inflammatory lesions upon the valves of the heart already 
diseased. 

The dangerous symptoms do not usually appear until after the first 
half of the pregnancy has passed, and the pregnancy seldom advances 
to term. No doubt many cardiac cases go through pregnancy and 

1 Arch. gen. de Med., vol. xiii. p. 291 

2 Obst. Journ., vol. v. p. 217. 



DISEASES OF PREGNANCY. 229 

labor without any untoward symptoms, and in these the compensatory 
hypertrophy of the heart is well marked. The pathological phenomena 
generally met with in fatal cases are pulmonary congestion, especially of 
the bronchial mucous membrane, and pulmonary oedema, with occasional 
pneumonia and pleurisy. Mitral stenosis seems to be the form of cardiac 
lesion most likely to prove serious, and, next to this, aortic incompetency. 
The obvious deduction from these facts is that heart disease, especially 
when associated with serious symptoms, such as dyspnoea, palpitation, 
and the like, should be considered a strong contra-indication of 
marriage. When pregnancy has actually occurred, all that can be 
done is to enjoin the careful regulation of the life of the patient, so as 
to avoid exposure to cold, and all forms of severe exertion. 

Syphilis. — The important influence of syphilis on the ovum is 
fully considered elsewhere (p. 249). As regards the mother, its effects 
are not different from those occurring at other times. It need only, 
therefore, be said that, whenever indications of syphilis in a pregnant 
woman exist, the appropriate treatment should be at once instituted and 
carried on during her gestation, not only with the view of checking 
the progress of the disease, but in the hope of preventing or lessening 
the risk of abortion, or of the birth of an infected infant. So far from 
pregnancy contra-indicating mercurial treatment, this rather is a 
reason for insisting on it more strongly. As to the precise medication, 
it is advisable to choose a form that can be exhibited continuously for 
a length of time without producing serious constitutional results. 
Small doses of the bichloride of mercury, such as one-sixteenth of a 
grain, thrice daily, or of the iodide of mercury, or of the hydrargyrum 
cum creta, in combination with reduced iron, answer the purpose 
well ; or, in the early stages of pregnancy, the mercurial vapor bath, 
or cutaneous inunction, may be employed. 

Dr. Weber, of St. Petersburg, 1 has made some observations showing 
the superiority of the latter methods, which he found did not interfere 
with the course of pregnancy ; the contrary was the case when the 
mercury Avas administered by the mouth, probably, as he supposes, 
from disturbance of the digestive system. It must be borne in mind 
that in married women it may sometimes be expedient to prescribe an 
anti-syphilitic course without their knowledge of its nature, so that 
inunction is not always feasible. 

Epilepsy. — The influence of pregnancy on epilepsy does not appear 
to be as uniform as might perhaps be expected. In some cases the 
number and intensity of the fits have been lessened, in others the dis- 
ease becomes aggravated. Some cases are even recorded in which 
epilepsy appeared for the first time during gestation. On account of 
the resemblance between epilepsy and eclampsia there is a natural 
apprehension that a pregnant epileptic may suffer from convulsions 
during delivery. Fortunately, this is by no means necessarily the 
case, and labor often goes on satisfactorily without any attack. 

Diseases of the Eye. — Certain diseases of the eye are observed 
during pregnancy. They have been well studied by Mr. Power. 2 One 

i Allgem. Med. Centr. Zeit, Feb. 1875. 2 Barnes: Obst.. Med., vol. i. p. 390. 



230 PREGNANCY. 

of the most common disturbances of vision is due to temporary im- 
pairment of accommodation, most generally in patients who are natur- 
ally hypermetropic, and dependent on exhaustion of the neuro-muscular 
apparatus. The symptoms are chiefly difficulty in reading, sewing, or 
other work requiring minute vision ; pain, black spots before the eyes, 
lachrymation, etc. Suitable convex glasses may be required, and with 
attention to the general health the symptoms may disappear. Other 
diseases more serious and lasting in their results are also met with. 
Mr. Power describes certain important changes in the eye met with in 
cases of albuminuria. The optic disk is swollen and congested, and 
irregular hemorrhages and white disks are seen in the retina. The 
hemorrhages he ascribes to actual rupture of the vessels; the white 
patches to a lesser degree of distention, admitting of the escape of 
white corpuscles through the vascular Avails. In many of these cases 
the vision was ultimately regained. Another form of disease he de- 
scribes is " white atrophy of the optic disk," probably following neu- 
ritis, occurring in cases in which there had been great loss of blood. 

Retinitis is of frequent occurrence in connection with albuminuria in 
pregnancy. It is not of grave import as regards the life of the patient, 
but very dangerous as regards vision, 23 33 per cent, of recorded cases 
having terminated in blindness, 58.25 per cent, in partial blindness. 
For retinitis occurring before the sixth month of pregnancy, Snell 1 ad- 
vises the induction of labor. 

Simple jaundice, having little serious effect on the mother, although 
probably tending to produce abortion, is occasionally met with in 
pregnancy. Such attacks may be transient, and may pass away with- 
out being attended with any bad consequence. Their production is 
probably favored by a slight degree of parenchymatous infiltration of 
the liver, which is a normal accompaniment of healthy pregnancy, as 
well as by the mechanical pressure of the gravid uterus on the intes- 
tines and the bile-ducts. Their symptoms do not differ from those of 
similar attacks in the non-pregnant state. 

The chief anxiety in regard to jaundice in pregnant women is that 
it is the frequent precursor of the serious disease known as "acute 
yellow atrophy of the liver," which is, as a matter of fact, a misnomer, 
the disease being a general one, of which the liver changes, though 
marked, are by no means an exclusive manifestation. 

Into the pathology and symptoms of this fatal illness it would be 
out of place to enter here at length. It is chiefly of moment to the 
obstetrician from the fact that it is undoubtedly more common in preg- 
nant women than in others. This is to be explained partly by the 
parenchymatous changes in the liver natural to pregnancy, partly to 
the impaired action of the kidneys, and to the altered state of the 
blood met with in that condition, the general toxaemia, characteristic 
of the disease, being ultimately increased by the retention of the bile- 
products. The prognosis, as regards the mother, is as bad as anything 
can be, very few cases, and these of a doubtful character, having re- 
covered. As regards the foetus, the issue is also almost necessarily 

1 Snell : Brit. Med. Journ., June 27, 1895. 



DISEASES OF PREGNANCY. 231 

fatal, and it has been noted that while the foetus perishes early in the 
course of the illness, there is not the same tendency for the uterus to 
throw off its contents which is observed in other conditions in which 
the ovum is destroyed, but that the dead and macerated foetus is retained 
Ml utero. 

The important point to decide in a suspected case is as to whether 
means should be taken to put an end to the pregnancy or not. This 
would appear to be a reasonable procedure, since the toxic conditions 
of the blood must go on increasing pari passu with pregnancy. Even 
this, however, is of doubtful expediency, for it has been observed that 
previously existing symptoms have become intensified after abortion, 
possibly from the increased weakness resulting from the hemorrhage 
accompanying it. 1 

Mollities Ossium. — The disease known as " mollities ossium," hap- 
pily a very rare one in this country, is of supreme importance as regards 
labor, in consequence of the severe pelvic deformity it causes, so often 
requiring the Caesarean section or Porro's operation. It appears to be 
now recognized that the proper course of procedure, when general thera- 
peutic measures have failed to do good, is to remove the uterine append- 
ages, for the double object of checking the progress of the disease and 
avoiding the risks connected with labor. 2 Should we meet with a case 
where pregnancy exists, probably the best course is to allow it to pro- 
ceed to term, and then resort to whatever obstetric course is deemed best. 

Carcinoma. — The occurrence of pregnancy in a woman suffering 
from malignant disease of the uterus is by no means so rare as might 
be supposed, and must naturally give rise to much anxiety as to the 
result. The obstetrical treatment of these cases will be discussed else- 
where. Should we be aware of the existence of the disease during 
gestation, the question will arise whether we should not attempt to 
lessen the risks of delivery by bringing on abortion or premature 
labor. The question is one which is by no means easy to settle. We 
have to deal with a disease which is certain to prove fatal to the mother 
before long, and the progress of which is probably accelerated after 
labor, while the manipulations necessary to induce delivery may very 
unfavorably influence the diseased structures. Again, by such a 
measure we necessarily sacrifice the child, while Ave are by no means 
certain that we materially lessen the danger to the mother. The ques- 
tion cannot be settled except on a consideration of each particular case. 
If we see the patient early in pregnancy, by inducing abortion we may 
save her the dangers of labor at term — possibly of the Csesarean sec- 
tion — if the obstruction be great. Under such circumstances, the 
operation would be justifiable. If the pregnancy has advanced beyond 
the sixth or seventh month, unless the amount of malignant deposit be 
very small indeed, it is probable that the risks of labor would be as 
great to the mother as at term, and it would then be iidvisable to give 
her the advantage of the few months' delay. If the malignant growth 
is of the epithelial variety, and limited to the cervix, it might in some 
cases be advisable to operate on it by amputating the cervix with the 

1 Lusk's Midwifery, 4th edition, p. 260. 2 Fehling: Arch. f. Gynak., vol. xlviii. 



232 PREGNANCY. 

ecraseur or galvano-caustic wire. This would probably be followed 
by abortion, which, under such conditions, would not be a disadvantage 
to the mother. 

Ovarian Tumor. — Cases are occasionally met with in which preg- 
nancy occurs in women who are suffering from ovarian tumor, and 
their proper management has given rise to considerable discussion. 
There can be no doubt that such cases are attended with very danger- 
ous and often fatal consequences, for the abdomen cannot well accom- 
modate the gravid uterus and the ovarian tumor, both increasing 
simultaneously. The result is that the tumor is subject to much con- 
tusion and pressure, which have sometimes led to the rupture of the 
cyst, and the escape of its contents into the peritoneal cavity ; at others 
to a low form of inflammation, attended with much exhaustion, the 
death of the patient supervening either before or shortly after delivery. 
The danger during delivery from the same cause, in the cases which 
go on to term, is also very great. Of thirteen cases of delivery by the 
natural powers, which I collected in a paper on " Labor Complicated 
with Ovarian Tumor," l far more than one-half proved fatal. Another 
source of danger is twisting of the pedicle, and consequent strangula- 
tion of the cyst, of which several instances are recorded. It is obvious, 
then, that the risks are so manifold that in every case it is advisable to 
consider Avhether they can be lessened by surgical treatment. 

The means at our disposal are either to induce labor prematurely, to 
treat the tumor by tapping, or to perform ovariotomy. The question 
has been particularly discussed by Spencer Wells in his works on 
Ovariotomy, and by Barnes in his Obstetric Operations. The former 
holds that the proper course to pursue is to tap the tumor when there 
is any chance of its being materially lessened in size by that procedure, 
but that when it is multilocular, or when its contents are solid, ovari- 
otomy should be performed at as early a period of pregnancy as pos- 
sible. Barnes, on the other hand, maintains that the safer course is to 
imitate the means by which Nature often meets this complication, and 
bring on premature labor without interfering with the tumor. He 
thinks that ovariotomy is out of the question, and that tapping may 
be insufficient and leave enough of the tumor to interfere seriously 
with labor. So far as recorded cases go, they unquestionably seem to 
show that tapping is not more dangerous than at other times, and that 
ovariotomy may be practised during pregnancy with a fair amount of 
success. Wells records ten cases which were surgically interfered with. 
In one, tapping was performed, and in nine ovariotomy ; and of these 
eight recovered, the pregnancy going on to term in five. On the other 
hand, five cases were left alone, and either went to term, or spontaneous 
premature labor supervened ; and of these, three died. Sir John 
Williams 2 has collected a number of cases, 371, from various sources. 
He finds that the mortality after tapping is 26 per ceut. ; after abortion 
and premature labor, 17 per cent. ; and after ovariotomy, 10 per cent. 
It is to be observed that, unless we give up all hope of saving the 

i Obst. Trans., vol. ix. p. 69. 2 Lancet, July 17, 1S97. 



DISEASES OF PREGNANCY. 233 

child, and induce abortion, the risk of induced premature labor, when 
the pregnancy is sufficiently advanced to hope for a viable child, would 
almost be as great as that of labor at term; for the question of inter- 
ference will only have to be considered with regard to large tumors, 
which would be nearly as much affected by the pressure of a gravid 
uterus at seven or eight months as by one at term. Small tumors gener- 
ally escape attention, and are more apt to be impacted before the present- 
ing part in delivery. The success of ovariotomy during pregnancy 
has certainly been great, and we have to bear in mind that the woman 
must necessarily be subjected to the risk of the operation sooner or 
later, so that we cannot judge of the case as one in which abortion 
terminates the risk. Even if the operation should put an end to the 
pregnancy — and there is at least a fair chance that it will not do so — 
there is no certainty that that would increase the risk of the operation 
to the mother, while as regards the child we should only have the same 
result as if we intentionally produced abortion. On the whole, then, 
it seems that the best chance to the mother, and certainly the best to 
the child, is to resort to the apparently heroic practice recommended 
by Wells. The determination must, however, be to some extent influ- 
enced by the skill and experience of the operator. If the medical 
attendant has not gained that experience which is so essential for a 
successful ovariotomist, the interests of the mother would be best con- 
sulted by the induction of abortion at as early a period as possible. 
One or other procedure is essential ; for, in spite of a few cases in 
which several successive pregnancies have occurred in women who 
have had ovarian tumors, the risks are such as not to justify an ex- 
pectant practice. Should rupture of the cyst occur, there can be no 
doubt that ovariotomy should at once be resorted to, with the view of 
removing the lacerated cyst and its extravasated contents. 

Fibroid Tumors. — Pregnancy may occur in a uterus in which there 
are one or more fibroid tumors. During pregnancy they may lead to 
premature labor or abortion, to peritonitis, or they may cause so much 
pain and discomfort from their size as to render interference imperative. 
If they are situated low down, and in a position likely to obstruct the 
passage of the foetus, they may very seriously complicate delivery. 
When they are situated in the fundus or body of the uterus they may 
give rise to risk from hemorrhage, or from inflammation of their own 
structure. Inasmuch as they are structurally similar to the uterine 
walls, they partake of the growth of the uterus during pregnancy, and 
frequently increase remarkably in size. Cazeaux says : " I have known 
them in several instances to acquire a size in three or four months which 
they would not have done in several years in the non-pregnant condi- 
tion." Conversely, they share in the involution of the uterus after 
delivery, and often lessen greatly in size, or even entirely disappear. 
Of this fact I have elsewhere recorded several curious examples ; l and 
nianv other instances of the complete disappearance of even large 
tumors have been described by authors whose accuracy of observation 
cannot be questioned. 

1 Obst. Trans., vol. x. p. 102; vol. xiii. 288; vol. xix., p. 101. 



234 PREGNANCY. 

The treatment will vary with the size and position of the tumor, and 
every case must be treated on its own merits, since it is not possible to 
lay down rules that will apply to all cases alike. A full report of all 
recent cases will be found in Dr. John Phillips's 1 paper, which shows 
how serious the results often are. If the position of the tumor be such 
as to to render it certain to obstruct delivery, the production of early 
abortion is perhaps the best course to pursue. It is not without serious 
risks, but probably less than allowing pregnancy to proceed to term. 
In several instances, either the removal of the tumor itself by abdom- 
inal section (myomectomy), or the removal of the tumor and the gravid 
uterus (Porro's operation), has been resorted to on account of the grave 
concomitant symptoms, and with a fair measure of success. If the 
tumor is well out of the way, interference is not so urgently called 
for. The principal danger then is that the tumor will impede the post- 
partum contraction of the uterus, and favor hemorrhage. Even if this 
should happen, the flooding could be controlled by the usual means, 
especially by the injection of the perchloride of iron. I have seen 
several cases in which delivery has taken place under such circum- 
stances without any untoward accident. The danger from inflamma- 
tion and subsequent extrusion of the fibroid masses would probably be 
as great after abortion or premature labor as after delivery at term. It 
seems, therefore, to be the proper rule to interfere when the tumors are 
likely to impede delivery, and in other cases to allow the pregnancy to 
go on, and be prepared to cope with any complications as they arise. 
The risks of pregnancy should be avoided in every case in which 
uterine fibroids of any size exist, the patients being advised to lead a 
celibate life. 



CHAPTEE IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua. — Comparatively little is, unfortunately, 
known of the pathological changes which occur in the mucous mem- 
brane of the uterus during pregnancy. It is probable that they are of 
much more consequence than is generally believed to be the case ; and 
it is certain that they are a frequent cause of abortion. 

One of the most generally observed probably depends on endome- 
tritis antecedent to conception. When the impregnated ovule reached 
the uterus, it engrafted itself on the inflamed mucous membrane, 
which was in an unfit condition for its reception and growth. A not 

1 " The Management of Fibro-myomata complicating Pregnancv and Labor." Brit. Med. Journ., 
vol. i. p. 1331. 



PATHOLOGY OF THE DECIDUA AND OVUM. 



235 



uncommon result, under such circumstances, is that the attachments of 
the ovum to the decidua are imperfectly formed, which greatly increases 
the liability to very early abortion from detachment of the ovum. In 
other cases abortion appears to be due to extravasations of maternal 
blood at the placental site, which occur during the period of active 
development of the placenta, from the second to the fifth month. As 
this morbid state of the uterine mucous membraue is likely to con- 
tinue after abortion is completed, the same history repeats itself on 
each impregnation, and thus we may have repeated early miscar- 
riages produced. It does not necessarily follow, however, that the preg- 
nancy is immediately terminated when this state of things is present. 



Fig. 87. 




Hypertrophied decidua laid open, with the ovum attached to its fundal portion. 
(After Duncan.) 



The unhealthy decidua (Fig. 87) may be expelled along with the 
ovum, or separately a few days later. It forms a tough, thick mem- 
brane, the internal surface of which is frequently studded with small 
polypoid growths. The occurrence of similar growths in the endome- 
trium of the non-gravid womb is of course well known, the condition 
being described by Olshausen as Endometritis fungosa. When occur- 
ring in the endometrium of the gravid womb it is called Endometritis 
decidualis fungosa. The microscopic changes which accompany this 
condition have not been well made out, but a good deal of hemorrhage 



236 PREGNANCY. 

and fatty degeneration are always found in the shed membrane. Doxat 
has described a ease of purulent decidual endometritis. He found the 
serotina permeated throughout with pus-cells, and a considerable layer 
of pus had collected between the chorion and the amnion. He believes 
the condition to have been caused by gonorrhoea, but admits the occur- 
rence to be extremely rare. 

The result of these alterations is frequently to produce dwind- 
ling or death of the ovum, which, however, retains its connection 
with the decidua, until, after a lapse of time, the decidua is expelled in 
the form of a thick triangular fleshy substance, with the atrophied 
ovum attached to some part of its inner surface. In other cases, in 
which the hyperplasia has advanced to a less extent, the nutrition of 
the foetus is not interfered with, and pregnancy may continue to term, 
the changes in the decidua being recognizable after delivery. Other 
diseases besides endometritis may give rise to similar alterations in the 
decidua, one of these being, as Virchow maintains, syphilis. The 
converse condition, an imperfect development of the decidua, especially 
of the decidua reflexa, has also been noted as a cause of abortion. The 
ovum will then hang loosely in the uterine cavity without the support 
which the growth of the decidua reflexa around it ought to afford, and 
its premature expulsion readily follows (Fig. 88). 

Fig. 83, 




Imperfectly developed decidua vera, with the ovum. (After Duncan.) 

Hydrorrhcea Gravidarum. — The peculiar condition known as 
hydrorrhea gravidarum most probably depends on some obscure mor- 
bid state of the uterine mucous membrane. By it is meant a discharge 
of clear watery fluid at intervals during pregnancy. It may happen 
at any period of gestation, but it is most commonly met with in the 
latter months. It may commence with a mere dribbling, or there may 
be a sudden and copious discharge of fluid. Afterward the watery 
fluid, which is generally of a pale-yellowish color and transparent like 
the liquor amnii, may continue to escape at intervals for many weeks, 



PATHOLOGY OF THE DECIDUA AND OVUM. 237 

and sometimes in very great abundance, so as to saturate the patient's 
clothes. Very frequently it is expelled in gushes, and at night, when 
the patient is lying quietly in bed ; its escape is then probably due to 
uterine contraction. 

Many theories have been held as to its cause. By some it is 
attributed to the rupture of a cyst placed between the ovum and the 
uterine walls ; Baudelocque referred it to a transudation of the liquor 
amnii through the membranes ; while Burgess and Dubois believed it 
to depend on a laceration of the membranes at a distance from the os 
uteri. Mattei more recently has attributed it to the existence of a sac 
between the chorion and the amnion. It may be that in some instances 
a single discharge of fluid may come from one of the two last- 
mentioned causes. But if it be continuous, or repeated, another source 
must be sought for. Hegar 1 maintains that it is the result of abun- 
dant secretion from the glands of the mucous membrane, which are in 
a state of chronic inflammation, the fluid accumulating between the 
decidua and chorion, and escaping through the os uteri. If this occur 
the decidua is probably in an hypertrophied and otherwise morbid 
state. Hydrorrhea is chiefly of interest from the error of diagnosis to 
which it is likely to give rise; for, on being summoned to a case in 
which watery discharge has occurred for the first time, we are naturally 
apt to suppose that the membranes have ruptured, and that labor is 
imminent. Nor is there any very certain means of deciding if this 
be so. In hydrorrhea, we find that pains are absent, the os uteri 
unopened, and ballottement may be made out. Even if the mem- 
branes be ruptured, there will be no indication for interference unless 
labor has actually commenced ; and the repetition of the discharge and 
the continuance of the pregnancy will soon clear up the diagnosis. 
Hydrorrhea, although apt to alarm the patient, need not give rise to 
any anxiety. The pregnancy generally progresses favorably to the 
full period, although in exceptional cases premature labor may super- 
vene. No treatment is necessary, nor is there any that could have 
the least effect in controlling the discharge. 

Pathology of the Chorion. — The only important disease of the 
chorion with which we are acquainted is the well-known condition 
which is variously described as uterine hydatids, cystic disease of the 
ovum, hydatidiform degeneration of the chorion, or vesicular mole. The 
name of uterine hvdatids was long given to it on the supposition that 
the grape-like vesicles which characterize the disease were true hydatids, 
similar to those which develop in the liver and other structures. This 
idea has long been exploded, and it is now known as a certainty that 
the disease originates in the villi of the chorion. The precise mode 
and the causes of its production are, however, not yet satisfactorily 
settled. The disease is characterized by the existence in the cavity of 
the uterus of a large number of translucent vesicles, containing a clear 
limpid fluid which has been found on analysis to bear close resemblance 
to the liquor amnii. These small bladder-like bodies, which vary in 
size from that of a millet-seed to an acorn, are often described as re- 

' Monat. i. Geburt, Bd. xxii. S. 429. 



238 



PREGNANCY. 



Fig. 89. 



sernbling a bunch of grapes or currants. On more minute examina- 
tion, they are found not to be each attached to independent pedicles, as 
is the case iu a bunch of grapes, but some of them grow from other 
vesicles, while others have distinct pedicles attached to the chorion, the 

pedicles themselves sometimes being dis- 
tended by fluid (Fig. 89). This peculiar 
arrangement of the vesicles is explained 
by their mode of growth. 

Causes. — There has been considerable 
discussion as to the etiology of this disease. 
By some it is supposed always to follow 
death of the foetus ; and the whole devel- 
opmental energy being expended on the 
chorion, which retains its attachment to 
the decidua, the result is its abnormal 
growth and cystic degeneration. This is 
the view maintained by Gierse and Graily 
Hewitt, and it is favored by the undoubted 
/^Qi* ' ' T '" 'd?^ -^ act ^ iat * n a ^ most a ^ cases the foetus has 
^##^ '"*'■ '" " ^l-v entirely disappeared, and by the occasional 

occurrence of cases of twin conceptions in 
which one chorion has degenerated, the 
other remaining healthy until term. On 
the other hand, it is maintained that the 
startiug-point is connected with the ma- 
ternal organism. Virchow thinks it origi- 
nates in a morbid state of the decidua ; 
while others have attributed it to some 
blood dyscrasia on the part of the mother, 
such as syphilis. There are many reasons for believing that causes of 
this nature may originate the affection. Thus it is often found to 
occur more than once in the same person ; and alterations of a similar 
kind, although limited in extent, are not unfrequently found in con- 
nection with the placenta and membranes of living children. On this 
theory the death of the foetus is secondary, the consequence of impaired 
nutrition from the morbid state of the chorion. The probability is 
that both views may be right, the disease sometimes following the 
death of the embryo, and at others being the result of obscure maternal 




Hydatidiform degeneration of the 
chorion. 



causes. 



Pathology. — The degeneration of the chorion villi generally com- 
mences at an early period of pregnancy, before the placenta has 
commenced to form. In that case, the entire superficies of the chorion 
becomes affected. The disease, however, may not begin until after the 
greater part of the chorion villi have atrophied, and then it is limited 
to the placenta. The epithelium of the villi is practically unaffected. 
The deep cellular layer disappears ; but the plasmodial layer remains 
intact, even in vesicles of large size, and often shows the proliferative 
changes characteristic of young placental tissue. The connective tissue 
stroma appears to be the seat of the disease. The earliest change is an 
increase in the size of the spaces of the normal structure by increase of 



PATHOLOGY OF THE DECIDUA AND OVUM. 239 

their fluid contents ; often a single large cell with a globular nucleus 
may be seen in the altered spaces. Gradually the spaces become more 
and more distended, and the connective tissue reticulum disappears ; so 
that the larger vesicles are simply hollow globes filled with fluid, the 
wall being composed of the epithelium of the villus. Thus are formed 
the peculiar grape-like bodies which characterize the disease. "When 
once the degeneration has commenced, the diseased tissue lias a re- 
markable power of increase, so that it sometimes forms a mass as large 
as a child's head, and several pounds in weight. 

The nutrition of the altered chorion is maintained by its connection 
with the decidua, which is also generally diseased and hypertrophied. 
Sometimes the adhesion of the mass to the uterine walls is very firm, 
and may interfere with its expulsion ; while, in a few rare cases, it has 
been found that the villi have forced their way into the substance of 
the uterus, chiefly through the uterine sinuses, and thus caused atrophy 
and thinning of its muscular structure. Cases of this kind are related 
by Volkmann, Waldeyer, 1 and Barnes, and it is obvious that the 
intimate adhesion thus effected must seriously add to the gravity of 
the prognosis. 

Taking this view of the etiology of this disease, it is obvious that it 
is essentially connected with pregnancy, and that there would be no 
valid ground for maintaining, as has sometimes been done, that it may 
occur independently of conception. It is just possible, hoAvever, that 
true entozoa may form in the substance of the uterus, which, being 
expelled per vaginam, might be taken for the results of cystic disease, 
and thus give rise to groundless suspicions as to the patient's chastity. 
Hewitt has related one case in which true hydatids, originally formed 
in the liver, had extended to the peritoneum, and were about to burst 
through the vagina at the time of death. This occurred in an unmar- 
ried woman. One or two other examples of true hydatids forming in 
the substance of the uterus are also recorded. A very interesting case 
is also related by Hewitt/ in which undoubted acephalocysts were 
expelled from the uterus of a patient who ultimately recovered. A 
careful examination of the cyst and its contents would show their true 
nature, as the echinococci heads, with their characteristic hooklets, 
would be discoverable by the microscope. 

It is also possible that unfounded suspicions might arise from the 
fact of a patient expelling a mass of hydatids long after impregnation. 
In the case of a widow, or woman living apart from her husband, 
serious mistakes might thus be made. This has been specially pointed 
out by McClintock, 3 who says : " Hydatids may be retained in utero 
for many months or years, or a portion only may be expelled, and the 
residue may throw out a fresh crop of vesicles, to be discharged on a 
future occasion." 

Symptoms and Progress. — The symptoms of cystic disease of the 
ovum are by no means well marked. At first there is nothing to point 
to the existence of any morbid condition, but as pregnancy advances 
its ordinary course is interfered with. There is more general dis- 

• Virchow Archiv. vol. xliv. p. 86 2 Obst. Trans., vol. xii. p. 273. 

3 McClintock's Diseases of Women, p. 398. 



240 



PREGNANCY. 



turbance of the health than there ought to be, and the reflex irritations, 
such as vomiting, may be unusually developed. The first physical sign 
remarked is rapid increase of the uterine tumor, which soon does not 
correspond in size to the supposed period of pregnancy. Thus, at the 
third month, the uterus may be found to reach up to, or beyond, the 
umbilicus. About this time there generally are more or less profuse 
watery and sanguineous discharges, which have been described as 
resembling currant juice. They no doubt depend on the breaking 
down and expulsion of the cysts caused by painless uterine con- 
tractions. They are sometimes excessive in amount, recur with great 
frequency, and often reduce the patient extremely. Portions of cysts 
may now generally be found mingled with the discharge, and eome- 
times large masses of them are expelled from time to time. Indeed, 
the discovery of portions of cysts is the only certain diagnostic sign. 
Vaginal examination, before the os has dilated, will give no informa- 
tion except the absence of ballottement. An unusual hardness or 
density of the uterus — described by Leishman, who attributes much 
importance to it, as " a peculiar doughy, boggy feeling" — has been 
pointed out by several writers. The contour of the uterine tumor, 



Fig. 90. 




Myxoma fibrosum of the placenta. (After Storch.) 

moreover, is often irregular. In addition, we, of course, fail to dis- 
cover the usual auscultatory signs of pregnancy. All this may aid in 
diagnosis, but nothing, except the presence of cysts in the watery bloody 
discharge, will enable us to pronounce with certainty as to the nature 
of the disease. 

Treatment. — As soon as the diagnosis is established, the indications 
for treatment are obvious. The sooner the uterus is cleared of its con- 
tents the better. Ergot may be given with advantage to favor uterine 



PATHOLOGY OF THE DECIDUA AND OVUM. 241 

contraction, and the expulsion of the diseased ovum. Should this fail, 
more especially if the hemorrhage be great, the fingers, or the whole 
hand, must be introduced into the uterus, and as much as possible of 
the mass removed. The uterine cavity should then be well washed 
out with an antiseptic solution, such as creolin and water, or water 
with sufficient tincture of iodine dropped into it to give it a sherry 
color. As the os is likely to be closed, its preliminary dilatation by 
Hegar's dilators, or by a Barnes's bag, if it be already opened to some 
extent, will in most cases be required. If chloroform be then admin- 
istered, the remaining steps of the operation will be easy. On account 
of the occasional firm adhesion of the cystic mass to the uterus, too 
energetic attempts at complete separation should be avoided. Any 
severe hemorrhage after the operation can be controlled by swabbing 
out the uterine cavity with the perchloride of iron solution. 

Myxoma Fibrosum. — Under the name of Myxoma jibrosum (Fig. 
90) a more rare degeneration of the chorion has been described by 
Virchow and Hildebrandt, 1 characterized, not by vesicular, but fibroid 
degeneration of the connective tissue of the chorion. It results in the 
enlargement of the chorionic villi by fibrous hypertrophy, formiug 
distinct tumors in the placental structure, and is more frequently met 
with in the later than in the earlier periods of pregnaucy. It does not, 
therefore, necessarily lead to the death of the child. 2 More recently a 
case has been recorded by Griffith 3 iu which a fleshy mole showed 
similar changes in a part of its extent. 

Deciduoma Malignum. — Perhaps a brief account may be given 
here — although, strictly speaking, the subject is more gynecological 
than obstetrical — of the so-called Deciduoma mallgnum. Much atten- 
tion has during the last few years been paid to a rapidly developing 
and exceedingly formidable type of malignant disease of the uterine 
body, not infrequently occurring after labor or abortion. Attention 
was first drawn to this subject by the publication of a case by Sauger 
in 1889. Since that a large number of articles and monographs have 
been written about it, and there is now quite an extensive literature 
on the subject, which has given rise to much discussion and difference 
of opinion. 

As to the clinical facts there is no doubt. Within a few weeks of 
labor or abortion the patient is attacked with severe and frequently 
recurring hemorrhage, which soon leads to great exhaustion and cachexia. 
This is followed by the occurrence of a watery, offensive, serosanguin- 
eous discharge. In many cases these symptoms have been taken to 
depend on retained portions of placenta, and the uterus has been very 
properly dilated, and the cavity explored under an anaesthetic, when 
no detached placental remains have been found, but one or more attached 
friable masses growing from the endometrium have been felt, breaking 
down under the finger, and easily removed for histological examination. 
Or perhaps the curette has been used without previous dilatation, and 
similar masses removed. The uterns is generally somewhat enlarged, 

i Monat. f. Geburt., May, 1895. 

2 Priestley : The Pathology of Intra-uterine Death, p. 156. 

3 Trans. Obst. Soc, vol. xxx. 

16 



242 PREGNANCY. 

the cavity dilated, and in cases which have not been recognized there 
may be secondary deposits about the vagina or vulva, or metastatic 
deposits in distant viscera. 

So far there is no divergence of opinion as to the symptoms and 
progress of this very active and dangerous form of intra-uterine malig- 
nant disease. The controversy which has raged with regard to it rather 
concerns its origin and its histological significance. 

There can be no doubt that recent pregnancy in some way or other 
predisposes to its development, and it is a curious fact that in a remark- 
ably large proportion of the recorded cases, in no less than 45 per cent., 
it followed the development of an hydatidiform mole. 

Its occurrence in connection with pregnancy involves the fact of its 
being found most often in young women between the ages of twenty 
and forty, at which ages other forms of malignant uterine disease are 
comparatively rare. 

The most generally received theory as to their origin is that these 
growths are developed from the villi either of a diseased or normal 
placenta. On histological examination they show characteristic plas- 
modial masses, which consist of multi-nucleated protoplasm, and these 
are either arranged in reticular or in isolated masses. These have been 
held by Marchand 1 and others to develop from the epithelial layer of 
the chorionic villi, the so-called " synctium/' but the ectoderm of the 
chorion villi also participate in their formation. Marchand explains 
the frequent connection of this disease with hydatidiform mole, by the 
fact that the chorionic villi penetrate the serotina more deeply in that 
disease than in ordinary pregnancy. 

These views have been critically examined by Eden, 2 who contends 
that there is no definite proof that these malignant growths necessarily 
originate in placental or chorionic structures. He believes them to be 
merely rapidly growing sarcomata affecting the uterine organs, and he 
has shown that precisely similar plasmodial masses, in every respect 
resembling the so-called " syncytium," are to be found in sarcoma of 
the testis and other parts of the body. 

Pathologists being as yet disagreed in this way, may be left to settle 
the question, which will no doubt be done in due time. 

The attention which has been paid to the subject has, however, 
familiarized us with the fact, which had previously been overlooked, 
that a virulent type of intra-uterine malignant disease is apt to develop 
in the puerperium. The symptoms are sufficiently characteristic, and 
the diagnosis, either by curetting or by dilatation, is easy. As to the 
treatment there can be no question. S~o time should be lost in experi- 
mental treatment. The instant the diagnosis is certain, and the removal 
of soft friable masses is quite sufficient to establish it, total extirpation 
of the uterus should at once be practised. Every day's delay only in- 
creases the danger of secondary deposit, and lessens the chance, unhap- 
pily in no case a very good one, of ultimate recovery. 

Pathology of the Placenta. — The pathology of the placenta has of 

i " Ueber die so-genannten deciduale Geschwiilfste." Monat f. Geburt und Gynak., 1895. 
2 "Deciduoma Malignum— a Criticism." Trans. Obst. Soc, vol. xxxviii. 



PATHOLOGY OF THE DECIDUA AND OVUM. 243 

late years attracted much attention, and it has an important practical 
bearing, in consequence of its effect on the child. 

Placentae vary considerably in shape. They may be crescentic, or 
spread over a considerable surface, in consequence of the chorion villi 
entering into communication with a larger portion of the decidua than 
usual (Placenta membranacea). Such forms, however, are merely of 
scientific interest. The only anomaly of shape of any practical im- 
portance is the formation of what have been called placenta? succenturiaz. 
These consist of one or more separate masses of placental tissue, pro- 
duced by the development of isolated patches of chorion villi. Hohl 
believes that they always form exactly at the junction of the anterior 
and posterior walls of the uterus, which in early pregnancy is a mere 
line. As the uterus expands, the portions of placenta on each side of 
this become separated from each other. They are only of consequence 
from the possibility of their remaining unnoticed in the uterus after 
delivery, and giving rise to secondary post-partum hemorrhage. The 
rare form of double placenta with a single cord, figured in the accom- 
panying woodcut (Fig. 91 ), was probably formed in this way, and the 
supplementary portion, in such a case, might readily escape notice. 

The placenta may also vary in dimensions. Sometimes it is of 
excessive size, generally when the child is unusually big, but not unfre- 
quently in connection with hydramnios, the child being dead and 
shrivelled. In other cases it is remarkably small, or at least appears 
to be so. If the child be healthy, this is probably of no pathological 
importance, as its smallness may be more apparent than real, depending 
on its vessels not being distended with blood. When true atrophy of 
the placenta exists, the vitality of the foetus may be seriously interfered 
with. This condition may depend either on a diseased state of the 
chorion villi, or of the decidua in which they are implanted. 1 The 
latter is the more common of the two ; and it generally consists in 
hyperplasia of the connective tissue of the decidua, which presses on 
the villi and vessels, and gives rise to general or local atrophy. The 
change is similar in its nature to that observed in cirrhosis of the liver, 
and certain forms of Bright's disease. It lias been specially studied 
by Hegar and Maier, 2 who describe it as beginning with a development 
of the elongated fusiform cells of the decidua, accompanied by an 
increase of the intercellular granular material. Eventually the cells 
undergo fatty degeneration, and the whole structure becomes fibroid. 
This has generally been ascribed to inflammatory changes, and, under 
the name of placentitis, has been described by many authors, and lias 
been considered to be a common disease. To it are attributed many 
of the morbid alterations which are commonly observed in placentae, 
such as hepatizations, circumscribed purulent deposits, and adhesions 
to the uterine walls. Many modern pathologists have doubted whether 
these changes are in any proper sense inflammatory. Whittaker 
observes on this point : " The disposition to reject placentitis altogether 
increases in modern times. Indeed, it is impossible to conceive of in- 
flammation on the modern theory (Cohnheim) of that process, since 

i Whittaker: Amer. Journ. of Obstet., vol. iii. p. 229. 
- Virchow's Archiv, 1871. 



244 



PREGNANCY 



there are no capillaries, in the maternal portion at least, through whose 
walls a ' migration ' might occur, and there are no nerves to regulate 
the contractility of the vessel-walls in the entire structure." Robin 



Fig. 91. 




Double placenta, with single cord. 



thus explains the various pathological changes above alluded to : 
" What has been taken for inflammation of the placenta is nothing else 
than a condition of transformation of blood-clots at various periods. 
What has been regarded as pus is only fibrin in the course of dis- 
organization, and in those cases where true pus has been found the pus 
did not come from the placenta, but from an inflammation of the tissue 
of the uterine vessels and an accidental deposition in the tissue of the 
placenta." The extravasations of blood here alluded to are of very 
common occurrence, and they are found in all parts of the organ ; in 
its substance, on its decidual surface, or immediately below the amnion, 
where they serve as points of origin for the cysts that are often there 
observed. The fibrin thus deposited undergoes retrograde metamor- 
phosis as in other parts of the body : it becomes decolorized, it under- 
goes fatty degeneration, or becomes changed into calcareous masses ; 
and in this way, it is supposed, may be explained the various patho- 
logical changes which are so commonly observed. The amount of 
retrograde metamorphosis, and the precise appearance presented, will, 
of course, depend on the time that has elapsed since the blood ex- 
travasations took place. 

Fatty degeneration of the placenta, and its influence on the 



PATHOLOGY OF THE DECIDUA AND OVUM. 



245 



nutrition of the foetus, have been specially studied in this country by 
Barnes and Druitt. Yellowish masses of varying sizes are very com- 
monly met with in placentae, and these are found to consist, in great 
part, of molecular fat, mixed with a fine network of fibrous tissue. 



Fig. 9 




Fatty degeneration of the placenta. 

The true fatty degeneration, however, specially affects the chorion villi 
(Fig. 92). On microscopic examination they are found to be altered 
and misshapen in their contour, and to be loaded with fine granular 
fat-globules. Similar changes are observed in the cells of the decidua. 
The influence on the foetus will, of course, depend on the extent to 
which the functions of the villi are interfered with. The probable 
cause of this degeneration is, no doubt, some obscure alteration in 
the nutrition of the tissue, depending on the state of the mother's 
health. The probability is that generally the fatty degeneration is 
not a primitive change, but a stage of some other morbid condition 
which precedes or is associated with it. Barnes believes that syphilis 
has much influence in its production. Druitt has pointed out that 
some amount of fatty degeneration is always present in a mature 
placenta, and is probably connected with the physiological separation 
of the organ ; and Goodell has more recently suggested that an unusual 
amount of this change may be merely an anticipation of the natural 
termination of the life of the placenta. 1 

Other morbid states of the placenta, of greater rarity, are occasion- 
ally met with, as an cedematous infiltration of its tissue, always occur- 

1 Amer. Journ. of Obstet., vol. ii. p. 535. 



246 



PREGNANCY. 



Fig. 93. 



ring, according to Lange, in cases of hydramnios, pigmentary and cal- 
careous deposits, and tumors of various kinds ; but these require only 
a passing mention. 

Before dismissing the subject of the morbid anatomy of the placenta, 
a word of caution must be uttered. It is only quite recently that the 
normal structure of the placenta, at all stages of gestation, has received 
anything, like the attention which the subject deserves, and thus there 
has been no reliable basis available for pathological observation. Some, 
at any rate, of the appearances described as pathological are now known 
to be quite unconnected with disease, and the number of such may in 
time become considerably increase J. For example, the observations 
of Barnes and Druitt upon fatty degeneration of the placenta, just re- 
ferred to, have been stated by Eden 1 to be open to serious objection. 
The specimens they examined were placentae which had been retained 
for some time in the uterus after the death of the foetus, and he believes 
that fatty degeneration always occurred in such placentae as a result of 
the suspension of the circulation through them. It is probable, there- 
fore, that the changes observed by these authors were post-mortem (as 
regards the foetus), and that it is therefore incorrect to cite them as a 
cause of the death of the foetus. 

Pathology of the Umbilical Cord. — The umbilical cord may be 
of excessive length, varying from eighteen to twenty inches, which is 

its average measurement, up to fifty or 
sixty inches, and a case is recorded in 
which it even reached the extraordinary 
length of nine feet. If unusually long 
it may be twisted round the limbs or neck 
of the child, and the latter position may, 
in exceptional instances, prove injurious 
during labor. 

Some authors refer cases of spontaneous 
amputation of foetal limbs in utero to con- 
strictions by the umbilical cord, but this 
accident is more probably produced by 
filamentous adnexa of the amnion. Knots 
in the cord are not uncommon, and they 
result from the foetus, in its movements, 
passing through a loop of the cord (Fig. 
93). If there is an average amount of 
Wharton's jelly in the cord the vessels 
are protected from pressure, and no bad 
effects follow. Gerry 2 attempts to show 
that such knots are more important than 
is generally believed, and relates two cases 
in which he believes them to have caused the death of the foetus. 

Extreme torsion of the cord, an exaggeration of the spiral twists 
generally observed, may prove injurious, and even fatal to the child by 
obstructing the circulation in the vessels. Spaeth mentions three cases 




Knots of the umbilical cord. 



i Journal of Pathology and Bacteriology, December, 1896. 
2 L'Union Medicale, October, 1876. 



PATHOLOGY OF THE DECIDUA AND OVUM. 247 

in which this caused the death of the foetus, the cord being twisted 
until it was reduced to the thickness of a thread. Some writers/ 
however, believe that extreme twisting of the cord is a post-mortem 
phenomenon following rotation of the foetus produced, after its death, 
by maternal movements. 

Anomalies in the distribution of the vessels of the cord are of 
common occurrence. The cord may be attached to the edge, instead 
of to the centre, of the placenta (battledore placenta). It may break 
up into its component parts before reaching the placenta, the vessels 
running through the membranes ; and if, in such a case, traction on 
the cord be made, the separate vessels may lacerate, and the cord 
become detached. There may be two veins and one artery, or only 
one vein and one artery, or there may be two separate cords to one 
placenta. These and other anomalies that might be mentioned are of 
little practical importance. 

Pathology of the Amnion. — The principal pathological condition 
of the amnion with which we are acquainted is that which is associated 
with excessive secretion of liquor amnii, and is generally known under 
the name of hydramnios, which term Ividd 2 limits to cases in which 
more than two quarts of amniotic fluid exist. Its precise cause is still 
a matter of doubt. By some it is referred to inflammation of the 
amnion itself; at other times it is apparently connected with some 
morbid state of the decidua, which may be found diseased and hyper- 
trophied. The foetus is very often dead and shrivelled, and the 
placenta enlarged and cedematous. It does not necessarily follow, 
however, that hydramnios causes the death of the child. Out of thirty- 
three cases McClintock found that nine children were born dead ; 3 and 
of the twenty-four born alive, ten died within a few hours, the re- 
mainder survived. There does not appear to be any marked relation 
between the state of the mother's health and the occurrence of this 
disease ; and it is certainly not necessarily present when the mother is 
suffering from dropsical effusions in other parts of the body. The 
theory that the disease is of purely local origin is favored by the fact 
that when hydramnios occurs in twin pregnancy one ovum only is 
generally affected. The probability is that most cases of hydramnios 
are of foetal origin, and are caused by some obstruction in the foetal 
circulation, mainly in the heart and liver, the latter often syphilitic. 
If the maternal placental circulation is active, and the foetal impeded, 
compensatory dropsical effusion into the sac of the amnion occurs as a 
consequence of the mechanical obstruction, and hydramnios results. 
Its effects, as regards the mother, are chiefly mechanical. It rarely 
begins to show itself before the fifth or sixth month of pregnancy, but 
when once it has commenced it rapidly produces a feeling of discom- 
fort and enlargement, altogether beyond that which should exist at the 
period of pregnancy which has been reached. In advanced stages the 
distress produced is often very great, the enlarged uterus pressing upon 
the diaphragm, and producing much embarrassment of respiration. 
Premature expulsion of the foetus very often supervenes. Four out of 

1 Schauta: Arch. f. Gyn., 1881, Bd. xix. S. 96. 

- "On the Diagnosis of Dropsy of the Amnion." Proceedings of the Obstetrical Society of 
Dublin, May 11, 1878. 3 Diseases of Women, p. 383. 



248 PKEGNANCY. 

McClintock's patients died after labor, showing that the maternal 
mortality is high — a result which he refers to the debilitated state of 
the women who were the subjects of the disease. 

Diagnosis. — The diagnosis is not, as a rule, difficult. It has to be 
distinguished from ascitic distention of the abdomen, from enlargement 
of the uterus from twin pregnancy, and from ovarian tumor, or preg- 
nancy complicated with ovarian tumor. The first will be recognized 
by the superficial position of the fluid; the difficulty of feeling the 
contour of the uterus, which is obscured by the surrounding fluid, and 
the results of percussion, which show that the fluid is free in the peri- 
toneal cavity ; and by the coexistence of dropsical effusions in other 
parts of the body. The second may be difficult, and even impossible, 
to diagnose from it: generally, however, in hydramnios the uterine 
tumor is more distinctly tense or fluctuating ; the foetal limbs cannot 
be felt on palpation ; and the lower segment of the uterus, as felt per 
vaginam, is unusually distended, the presenting part not being appreci- 
able. Ovarian tumors, alone or complicating pregnancy, may also be 
difficult to distinguish from dropsy of the amnion. The general history 
of the case, and the presence or absence of signs of pregnancy, may 
enable us to arrive at a diagnosis ; and Kidd points out that the posi- 
tion of the uterus, whether gravid or not, is usually low down in the 
pelvis in ovarian dropsy, while in dropsy of the amnion it is drawn 
high up, and reached with difficulty on vaginal examination. 

During labor an excessive amount of liquor amnii is often a cause 
of deficient uterine action and delay, the pains being feeble and in- 
effective. This, of course, tells chiefly in the first stage, which is often 
much prolonged, unless the membranes are punctured early, and the 
superabundant fluid is allowed to escape. 

Treatment. — No treatment is known to have any effect on the 
disease. If the discomfort and distention are very great, it may be 
absolutely necessary to puncture the membranes, and allow the water 
to escape. This inevitably brings on labor. If the pregnancy be not 
sufficiently advanced to give hope for the birth of a living child, we 
would not, of course, resort to this expedient unless the mother's 
health was seriously imperilled. It is possible that in such cases the 
patient might be relieved by inserting a minute aspirating needle 
through the os, and removing a certain quantity of the liquor amnii 
by aspiration, without inducing the labor. I have never had an oppor- 
tunity of trying this expedient, but it seems a possibility. 

Deficiency of Liquor Amnii. — A defective amount of liquor 
amnii is said to favor certain malformations, by allowing the uterus to 
compress the foetus unduly. It certainly occasionally gives rise to 
adhesion between the foetus and the membranes, and to the formation 
of amniotic bands which are capable of producing certain foetal de- 
formities (pp. 247, 252). 

The liquor amnii itself varies much in appearance. It is sometimes 
thick and treacly, instead of limpid, and it may be offensive in odor. 
The cause of these variations is not well understood. 

Pathology of the Foetus. — There is abundant evidence that the 
foetus in utero is subject to many diseases, some of which cause its 



PATHOLOGY OF THE DECIDUA AND OVUJI. 249 

death, and others leave distinct traces of their existence, although not 
proving fatal. The subject is of great importance, and is well worthy 
of study. There is still much to be done in this direction, which may 
lead to important practical results. I can, however, do little more 
than enumerate some of the principal affections which have been 
observed. 

Diseases Transmitted through the Mother. — It is a well-estab- 
lished fact that the various eruptive fevers from which the mother may 
suffer may be communicated to the foetus in utero. When the mother 
is attacked with confluent smallpox she almost always aborts, but not 
necessarily so when it is discrete or modified. In such cases it has 
often happened that the foetus has been born with evident marks of 
smallpox. Cases are on record which prove that the foetus was 
attacked subsequently to the mother. Thus a mother attacked with 
smallpox has miscarried, and has given birth to a living child showing 
no trace of the disease, which, however, showed itself in two or three 
days; proving that it had been contracted, and had run through its 
usual period of incubation, when the foetus was still in utero. It does 
not follow, however, that the foetus is affected, as Serres has collected 
twenty-two cases in which women suffering from smallpox gave birth 
to children who had not contracted the disease. It has been supposed 
that in such cases the child is protected from smallpox, though it has 
shown no symptom of having had the disease. Tarnier, however, 
cites two instances in which such children had smallpox two years 
after birth. Madge and Simpson record cases in which vaccination 
performed on the mother during pregnancy protected the foetus, on 
whom all subsequent attempts at vaccination failed. There is evidence 
also to prove that the disease may be transmitted to the foetus through 
a mother who is herself unsusceptible of contagion; the child having 
been covered with smallpox eruption, the mother being quite free from 
it. It is probable that the same facts which have been observed with 
regard to smallpox hold true with reference to other zymotic diseases, 
such as scarlet fever and measles, although there is not sufficient 
evidence to justify a positive assertion to that effect. 

Amongst other maternal diseases, malaria and lead-poisoning are 
known to affect the foetus in utero. Dr. Stokes relates cases in which 
the mother suffered from tertian ague, the child having also attacks, as 
evidenced by its convulsive movements, appreciable by the mother, 
which took place at the regular intervals, but at a different time from 
the mother's paroxysms. In other cases the febrile paroxysm comes 
on at the same time in the foetus as in the mother; and the fact has 
been verified by the observation that the paroxysms continued to recur 
simultaneously after delivery. The foetus has also been born with dis- 
tinct malarious enlargement of the spleen. From the frequency with 
which largely hypertrophied spleens are seen in mere infants in 
malarious districts, I imagine that the intra-uterine disease must be 
common. I have frequently observed this fact in India, although, of 
course, without any possibility of ascertaining if the mothers had 
suffered from intermittent fever during pregnancy. Lead-poisoning is 
also known to have a most prejudicial effect on the foetus, and fre- 



250 PREGNANCY. 

quently to lead to abortion. M. Paul has collected eighty-one cases 1 
in which it caused the death of the foetus, in some not until after birth; 
and occasionally it seems to have affected the foetus even when the 
mother escaped. 

Of all blood-dyscrasise transmitted to the foetus, the most important 
is syphilis. Its influence in producing repeated abortion is elsewhere 
described (p. 259). It may unquestionably be transmitted to the foetus 
without producing abortion, and at term the mother may be either 
delivered of a living child, bearing evident traces of the disease ; of a 
dead child similarly affected; or of an apparently healthy child in 
whom the disease develops after a lapse of a month or two. These 
varying effects probably depend on the intensity of the poison ; and 
the longer the time that has elapsed since the origin of the disease 
in the affected parent, the better will be the chance for the child. The 
disease is, no doubt, generally transmitted through the mother, and if 
she be affected at the time of conception, the infection of the foetus 
seems certain. If, however, she contracts the disease at an advanced 
period of pregnancy, the child may entirely escape. Ricord even 
believes that syphilis contracted after the sixth month of pregnancy 
never affects the child. The father alone may transmit the disease to 
the ovum ; and Hutchinson has recorded cases to show that the mother 
may become secondarily affected through the diseased foetus. The 
evidences of syphilitic taint in a living or dead child are sufficiently 
characteristic. The child is generally puny and ill-developed. An 
eruption of pemphigus is common, either fully-developed bullae, or 
their early stage, when they form circular copper-colored patches. 
This eruption is always most marked on the hands and feet, and a 
child born with such an eruption may be certainly considered syphi- 
litic. On post-mortem examination the most usual signs are small 
patches of suppuration in the thymus, similar localized suppurations 
in the tissues of the lungs, indurated yellowish patches in the liver, 
and peritonitis, the importance of which in causing the death of syphi- 
litic children has been specially dwelt on by Simpson. 2 

The most important of the inflammatory diseases affecting the foetus 
is peritonitis. Simpson has shown that traces of it are very frequently 
met with, and that it is not always syphilitic. Sometimes it has been 
observed when the mother has been in bad health during pregnancy, 
and at others it seems to have resulted from some morbid condition 
of the foetal viscera. Pleurisy with effusion is another inflammatory 
affection which has been noticed. 

The dropsical affections most generally met with are ascites and 
hydrocephalus, which may both have the effect of impeding delivery. 
Of these, hydrocephalus is the more common, and may give rise to 
much difficulty in labor. Its causes are uncertain, but it probably 
depends on some altered state of the mother's health, as it is apt to 
recur in several successive pregnancies, and is not infrequently asso- 
ciated with an imperfectly developed vertebral column and spina bifida. 

i Arch, gen de. Med., 1860. 
2 Obst Works, vol. i. p. 117. 



PATHOLOGY OF THE DECIDUA AND OVUM. 251 

The fluid collects in the ventricles, which it greatly distends, arid these 
then produce expansion and thinning of the cranium, the bones of 
which are widely separated from each other at the sutures, which are 
prominent and fluctuating. In a few cases internal hydrocephalus 
may be complicated, and the diagnosis in labor consequently obscured 
by the coexistence of what has been called "external hydrocephalus." 
This consists of a collection of fluid between the skull and the scalp, 
which may be either formed there originally or may collect from a 
rupture of one of the sutures or fontanelles during labor, through 
which the intra-cranial fluid escapes. 

Ascites is generally associated with hydramnios, and sometimes with 
hydrothorax, or other dropsical effusions. It is a rare affection, and 
according to Depaul 1 extreme distention of the bladder is not un- 
frequently mistaken for it. 

Tumors of different kinds may be met with in various parts of the 
child's body, which sometimes grow to a great size and impede delivery. 
Tarnier records cases of meningocele larger than a child's head, and 
large cystic growths have been observed attached to the nates, pectoral 
region, or other parts of the body. Cancerous tumors of considerable 
size, either external or of the viscera, have also been met with. Other 
foetal tumors may be produced by congenital deformities, such as pro- 
jection of the liver or other abdominal viscera through a deficiency of 
the abdominal wall ; or spina bifida from imperfectly developed verte- 
brae. The amount of dystocia produced by such causes will, of course, 
vary much in proportion to the size, consistency, and accessibility of 
the tumor. 

Wounds and Injuries of the Foetus. — Accidents of serious gravity 
to the foetus may happen from violence to which the mother has been 
subjected, such as falls or blows, without necessarily interfering with 
gestation. Many curious examples of this kind are on record. Thus 
a child has been born presenting a severe lacerated wound extending 
the whole length of the spine, where both the skin and the muscles 
had been torn, and which seems to have resulted from the mother 
having fallen in the last month of pregnancy. Similar lacerations and 
contusions have been observed in other parts of the body, the wounds 
being in various stages of cicatrization, corresponding to the lapse of 
time since the accident had occurred. Intra-uterine fractures are not 
rare, apparently arising from similar causes. In some of these cases 
the broken ends of the bones had united, but, from want of accurate 
apposition, at an acute angle, so as to give rise to much subsequent 
deformity. Chaussier records two cases in which there were many 
fractures in the same child — in one, one hundred and thirteen, and in 
another forty-two — which were in different stages of repair. He 
attributes this curious occurrence to some congenital defect in the 
nutrition of the bones, possibly allied to mollities ossium. 2 

Intra-uterine amputations of foetal limbs have not unfrequently been 
observed. Children are occasionally born with one extremity more or 

1 Tanner's Cazeaux, p. 855. * Gazette hebdom., 1S60. 



252 



PKEGNANCY. 



Fig. 94. 




Intra-uterine amputation of both 
arms and legs. 



less completely absent, and cases are known in which the whole four 
extremities were wanting (Fig. 94). The mode in which these mal- 
formations are produced has given rise to 
much discussion. At one time it was sup- 
posed that the deficiency of the limb was due 
to gangrene of the extremity, and subsequent 
separation of the sphacelated parts. Reuss, 
who has studied the whole subject very 
minutely, 1 considers gangrene in the unrup- 
tured ovum to be an impossibility, for that 
change cannot occur unless there is access of 
air, and when portions of the separated 
extremity are found in utero, as is often the 
case, they show evidences of maceration, but 
not of decomposition. The general belief is 
that these intra-uterine amputations depend 
on constriction of the limb by folds or bands 
of the amnion — most often met with when 
the liquor amnii is deficient in quantity — « 
which obstruct the circulation, and thus give 
rise to atrophy of the part below the constric- 
tion. It has been supposed that the umbilical 
cord might, by encircling the limb, produce a like result. It appears 
doubtful, however, whether this cause is sufficient to produce complete 
separation of the limb, as any great amount of constriction would 
interfere with the circulation through the cord. Sometimes, when 
intra-uterine amputation occurs, the separated portion of the limb is 
found lying loose in the amniotic cavity, and is expelled after the 
child. Cases of this kind have been recorded by Martin, Chaussier, 
and Watkinson. More often no trace of the separated extremity can 
be found. The explanation probably depends upon the period of utero- 
gestation at which amputation took place. If it occurred at a very 
early period of pregnancy, before the third month, the detached portion 
would be minute and soft, and would easily disappear by solution. If 
at a later period, this could hardly happen, and the detached portion 
would remain in utero. In cases of the latter kind cicatrization of the 
stump has often been observed to be incomplete. Simpson pointed out 
the occasional existence of rudimentary fingers or toes on the stump of 
an amputated limb, such as are seen on the thighs in Fig. 97. These 
he attributed to an abortive reproduction of the separated extremity, 
analogous to what is observed in some of the lower animals. This 
explanation has been contested with much show of reason. Martin 
believes that the reproduction is only apparent, and that the rudi- 
mentary extremities are, in reality, instances of arrested development. 
The constricting agents interfered with the circulation sufficiently to 
arrest the growth of the limb below the site of constriction, but not 
sufficiently to effect complete separation. If constriction occurred at a 
very early stage of development, an appearance similar to that observed 



1 Scanzoni's Beitrage, 1869. 



PATHOLOGY OF THE DECIDUA AND OVUM. 253 

by Simpson would be produced. It does not follow, however, that all 
cases of absence of limbs depend on intra-uterine amputations. In 
some cases they would appear to be the result of a spontaneous arrest 
of development, or of congenital monstrosity. Mr. Scott ! relates a 
case in which a distinct hereditary tendency was evident, and here the 
deformity certainly could not have resulted from the constriction of 
amniotic bands. In this family the grandfather had both forearms 
wanting, with rudimentary fiugers attached ; the next generation 
escaped ; but the grandchild had a deformity precisely similar to the 
grandfather. 

Maternal Impressions. — From time immemorial it has been be- 
lieved that strong maternal impressions during pregnancy may in 
some way modify the offspring. An instance of this is recorded so 
anciently as in Genesis xxx., in the transactions between Jacob and 
Laban. Several of the ancient writers, such as Paulus Oegineta, who 
quotes many authorities, Ambrose Pare, and others, give instances of 
it, and the possibilty of such au influence is a widespread belief. Most 
of the recorded cases, however, are unreliable and will not stand inves- 
tigation. It is obvious that the weight of scientific argument is against 
this hypothesis. Most of the monstrosities supposed to be produced 
iu this way, such as children born without arms and the like, must 
have originated in very early pregnancy from some embarrassment in 
natural development long before the supposed exciting cause came into 
operation. The probability is that when a malformed child is born 
the tendency in the lay mind is to look back for some cause, and it is 
rarely that a pregnant woman cannot find something or other to lend 
itself to this theory. 

So completely had the profession in recent times concluded that there 
was no scientific basis for the theory that it is not even mentioned in 
most modern works on midwifery. The subject cannot, however, be 
so easily dismissed. 

Fordyce Barker 2 has written an interesting paper on it, in which he 
collects a number of curious and apparently authentic cases. He cites 
Rokitansky, Carpenter, Geoffroy, St. Hilaire, Allen Thomson, and 
other eminent anatomists and physiologists as believing in the possibility 
of maternal impressions being conveyed to the foetus. He contends 
that the causes should be habitual, acting on the foetus through the 
blood, and early in pregnancy. 

Causes acting before conception are easily intelligible, and would then 
be in the nature of heredity. All that can safely be said is that the 
vast majority of supposed cases of the kind will not stand criticism. 

In the face, however, of so long-established and widespread a belief, 
which like most such beliefs is probably founded on observation, and 
of the numerous instances recorded even in modern times by reliable 
observers, it would not be safe to deny altogether the possibility of such 
an occurrence. 

The subject is one which must as yet be left undecided, and which 
calls for a more thorough and accurate study than it has yet received. 

1 Obst Trans., vol. xiii. p. 94. 

2 The Influence of Materual Impressions on the Fcetus. 



254 PREGNANCY. 

Death of Foetus. — When from any cause the foetus has died during 
pregnancy, it may be either soon expelled, or it may be retained in utero 
for a longer or shorter time, or even to the full period. The changes 
observed in such foetuses vary considerably according to the age of the 
foetus at the time of death, or the time that it has been retained in 
utero. If it die at an early period, when the tissues are very soft, it 
may entirely dissolve in the liquor amnii, and no trace of it may be 
found when the membranes are expelled. Or it may shrivel or mum- 
mify; and if this happen in a twin pregnancy, as sometimes occurs, 
the growing foetus may compress and flatten the dead one against the 
uterine wall. 

At a later period of pregnancy a dead foetus undergoes changes 
ascribed to putrefaction, but which produce appearances different from 
those of decomposition in animal textures exposed to the atmosphere. 
There is no offensive smell, as in ordinary decay. The tissues are all 
softened and flaccid. The more manifest changes are in the skin, the 
epidermis of which is separated from the cutis vera, which has a deep 
reddish color. This is especially apparent on the abdomen, which is 
flaccid, and hollow in the centre. The internal organs are much 
altered. The brain is diffluent and pulpy, and the cranial bones loose 
within the scalp. The structures of the muscles and viscera are in 
various stages of transformation, many having undergone fatty changes, 
and contain crystals of margarin and cholesterin. The extent to which 
these changes occur depends, in a great measure, on the length of time 
the foetus has been dead, but they do not admit of our estimating with 
any degree of accuracy what that time has been. 

The symptoms and diagnosis of the death of the foetus may here 
be considered. They are, unfortunately, not very reliable. The cessa- 
tion of the foetal movements cannot be depended on, as they are 
frequently unfelt for days or weeks, when the child is alive and well. 
Sometimes the death of the foetus is preceded by its irregular and 
tumultuous movements, and, in women who have been delivered of 
several dead children in succession, this sensation may guide us in our 
diagnosis. This suspicion may be confirmed by auscultation. The 
mere fact that we are unable, at any given time, to hear the foetal heart 
will not justify an opinion that the foetus is dead. If, however, the 
foetal heart has been distinctly heard, and after one or two careful 
examinations, repeated at separate times, it cannot again be made out, 
the probability of the child being dead may be assumed. Certain 
changes in the mother's health have been noted in connection with 
the death of the foetus, such as depression and lowness of spirits, a 
feeling of coldness and weight about the lower parts of the abdomen, 
paleness of the face, a livid circle round the eyes, irregular shiverings 
and feverishness, shrinking of the breasts, and diminution in the size 
of the abdominal tumor. All these, however, are too indefinite to 
justify a positive diagnosis, and they are not infrequently altogether 
absent. At most they can do no more than cause a suspicion as to 
what has happened. 



ABORTION AND PREMATURE LABOR. 255 



CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Importance and Frequency of Abortion. — The premature ex- 
pulsion of the foetus is an event of great frequency. The number of 
foetal lives thus lost is enormous. There are few multipara who have 
not aborted at one time or other of their lives. Hea:ar estimates that 
about one abortion occurs to every eight or ten deliveries at term. 
Whitehead has calculated that at least 90 per cent, of married women 
who lived to the change of life had aborted. The influence of this 
incident on the future health of the mother is also of great importance. 
It rarely, indeed, proves directly fatal, but it often produces great 
debility from the profuse loss of blood accompanying it ; and it is one 
of the most prolific causes of uterine disease in after-life, possibly 
because women are apt to be more careless during convalescence than 
after delivery, and the proper involution of the uterus is thus more 
frequently interfered with. 

Definition. — A not uncommon division of the subject is into abortion, 
miscarriage, and 'premature labor, the first name being applied to expul- 
sion of the ovum before the end of the fourth month of utero-gestation ; 
miscarriage, to expulsion from the end of the fourth to the end of the 
sixth month ; and premature labor, to expulsion from the end of the 
sixth month to the term of pregnancy. This is, however, a needless 
and confusing subdivision, which leads to no practical result. It 
suffices to apply the term abortion or miscarriage indiscriminately to 
all cases in which pregnancy is terminated before the foetus has arrived 
at a viable age, and premature labor to those in which there is a possi- 
bility of its survival. There is little or no hope of a foetus living 
before the twenty-eighth week or seventh lunar month, and this period 
is therefore generally fixed on as the limit between premature labor and 
abortion. The rule is, however, not without an occasional, although 
very rare, exception. Dr. Keiller, of Edinburgh, has recorded an 
instance in which a foetus was born alive at the fourth month, nine 
days after the mother had experienced the sensation of quickening. I 
myself recently attended a lady who miscarried in the fifth month of 
pregnancy, the child being born alive, and living for three hours. 
Several cases are on record in which after delivery in the sixth month 
the child survived and was reared. The possibility of the birth of a 
living child under such circumstances should be recognized, as it may 
give rise to legal questions of importance ; but the exceptions to the 
ordinary rule are so rare that they need not interfere with the division 
of the subject usually made. 

Abortion is Most Common in Multiparae. — Multiparse abort far 



256 PREGNANCY 

more frequently than prirniparse. This is contrary to the statement in 
many obstetrical works. Thus, Tyler Smith says, " there seems to be 
a greater danger of this accident in the first pregnancy." Schroeder, 1 
however, states that twenty-three multipara? abort to three primiparse ; 
and Dr. Whitehead, of Manchester, who has particularly studied the 
subject, believes that abortion is more apt to occur after the third and 
fourth pregnancies, especially when these take place toward the time 
for the cessation of menstruation. 

There can be no doubt that women who have aborted more than once 
are peculiarly liable to a recurrence of the accident. This can generally 
be traced to the existence of some predisposing cause which persists 
through several pregnancies, as, for example, a syphilitic taint, a 
uterine flexion, or a morbid state of the lining membrane of the uterus. 
It is probable that in many women a recurrence of the accident induces 
a habit of abortion, or perhaps it might be more accurate to say, a 
peculiar irritable condition of the uterus, which renders the continuance 
of pregnancy a matter of difficulty, independently of any recognizable 
organic cause. 

The frequency of abortion varies much at different periods of preg- 
nancy ; and it occurs much more often in the early months, because of 
the comparatively slight connection then existing between the chorion 
and the decidua. At a very early period of pregnancy the ovum is 
cast off with such facility, and is of such minute size, that the fact of 
abortion having occurred passes unrecognized. Very many cases, in 
which the patient goes one or two weeks over her time, and then has 
what is supposed to be merely a more than usually profuse period, are 
probably instances of such early miscarriages. Velpeau detected an 
ovum, of about fourteen days, which was not larger than an ordinary 
pea, and it is easy to understand how so small a body should pass 
unnoticed in the blood which escapes along with it. 

Up to the end of the third month, when miscarriage occurs, the ovum 
is generally cast off en masse, the decidua subsequently coming away in 
shreds or as an entire membrane. The abortion is then comparatively 
easy. From the third to the sixth month, after the placenta is formed, 
the amnion is, as a rule, first ruptured by the uterine contractions, and 
the foetus is expelled by itself. The placenta and membranes may then be 
shed as in ordinary labor. It often happens, however, that on account of 
the firmness of the placental adhesion at this period the secundines are 
retained for a greater or less length of time. This subjects the patient 
to many risks, especially to those of profuse hemorrhage, and of septi- 
caemia. For this reason, premature termination of the pregnancy is 
attended by much greater danger to the mother between the third and 
sixth months than at an earlier or later date. After the sixth month 
the course of events is not different from that attending ordinary labor. 
The prognosis to the child is more unfavorable in proportion to the 
distance from the full period of gestation at which premature labor 
takes place. 

Causes. — The causes of abortion may conveniently be subdivided 

1 Schroeder : Manual of Midwifery, p. 149. 



ABORTION AND PREMATURE LABOR. 257 

into the predisposing and exciting, the latter being often slight, and such 
as would have no effect in inducing uterine contractions in women 
unless associated with one or more of the former class of causes. The 
predisposition to abortion may depend on some condition interfering 
with the vitality of the ovum, or its relation to the maternal structures, 
or on certain conditions directly affecting the mother's health. 

One of the most common antecedents of abortion is the death of the 
foetus, which leads to secondary changes, and ultimately produces the 
uterine contractions which end in its expulsion. The precise causes of 
death in any given case cannot always be accurately ascertained, as 
they sometimes depend on conditions which are traceable to the 
maternal structures, at others to the ovular, or, it may be, to a combina- 
tion of the two. Xor does it by any means follow that the death of the 
ovuni immediately results in its expulsion. The mode in which death 

Fig. 95. 




An apoplectic ovum, with blood effused in masses under the foetal surface 
of the membranes. 

of the ovum produces abortion is not difficult to understand, for it 
necessarily leads to changes in the relations between the ovular and 
maternal structures ; these changes cause hemorrhages — partly external 
and partly into the membranes — which, in their turn, excite uterine 
contraction. Extravasations of blood may take place in various posi- 
tions. One of the most common is into the decidual cavity, between 
the decidua vera and the decidua reflcxa, or between the decidua vera 
and the uterine walls. If the hemorrhage is only slight, and especially 
if it comes from that portion of the decidua near the internal os, and 
at a distance from the ovum, there need be no material separation, and 
pregnancy may continue. This explains the cases occasionally met 
with in which there is more or less hemorrhage, without subsequent 

17 



258 



PREGNANCY. 



abortion. When the amount of extra vasated blood is at all great 
separation and abortion necessarily result, and the decidua will be 
found on expulsion to have coagula on its surface, and between its 
various layers which are found to project into the cavity of the amnion 
(Fig. 95). In other cases hemorrhage is still more extensive, and, after 
breaking through the decidua reflexa, it forms clots between it and the 
chorion, and even in the cavity of the amnion. Supposing expulsion 
to take place shortly after coagula are deposited among the membranes, 
the blood is little altered, and we have an ordinary abortion. If, how- 
ever, the ovum is retained, the coagulated fibrin and the placenta or 
membranes undergo secondary changes which lead to the formation of 
moles. The so-called fleshy mole (Fig. 96) is often retained for many 
weeks or months after the death of the foetus, and during this time 
there may be but little modification of the usual symptoms of preg- 




Blighted ovum, with fleshy degeneration of the membranes. 



nancy ; or, as is frequently the case, it gives rise to occasional hemor- 
rhage, until at last uterine contractions come on, and it is cast off in 
the form of a thick fleshy mass having but little resemblance to the 
ordinary products of conception. The most probable explanation of 
its formation is that when hemorrhage originally took place the 
effusion of blood was not sufficient to effect the entire separation and 
expulsion of the ovum. Part of the membranes or of the placenta — 
if that organ had commenced to form — retained its organic connection 
with the uterus, while the foetus perished. The attached portion of 
the placenta or membranes continues to be nourished, although abnor- 
mally. The foetus generally entirely disappears, especially if it has 
perished at an early period of utero-gestation, when it becomes dissolved 
in the liquor amnii : or it may become macerated, shrivelled, and 
greatly altered in appearance. The effused blood becomes decolorized 



ABORTION AND PREMATURE LABOR. 259 

from the absorption of the corpuscles ; and, according to Seanzoni, 
fresh vessels are developed in the fibrin, which increase the vascular 
attachment of the mole to the uterine walls. The placenta and mem- 
branes may go on increasing in thickness until they form a mass of 
considerable size. Careful microscopic examination will almost always 
enable us to discover the villi of the chorion, altered in appearance, often 
loaded with granular fatty molecules, but sufficiently distinct to be 
readily recognizable. 

Important as are the causes of abortion arising from some morbid 
condition of the ovum, they are not more so than those which depend 
on the maternal state ; and it is to be observed that the former are often 
indirect causes produced by primary maternal changes. Many of these 
maternal causes act by producing hypersemia of the uterus, which leads 
to extravasation of blood. Thus abortion is apt to occur in women who 
lead unhealthy lives, such as those who occupy overheated and ill- 
ventilated rooms, or indulge to excess in the fatigues and pleasures of 
society, in the use of alcoholic drinks, and the like. Over-frequent 
coitus has been, for the same reason, observed to produce a remarkable 
tendency to abortion, and Parent-Duchatelet has noted that it is of 
very frequent occurrence amongst women of loose life. Many diseases 
strongly predispose to it, such as fevers, zymotic diseases of all kinds, 
measles, scarlet fever, smallpox, and diseases of the respiratory organs, 
such as bronchitis and pneumonia. Syphilis is well known to be one 
of the most frequent causes, and one that is likely to act in successive 
pregnancies. It may act so that the pregnancy is brought to a pre- 
mature termination, time after time, until the constitutional disease is 
eradicated by appropriate treatment. It acts in some cases through 
the influence of the father in producing a diseased ovum ; and it is the 
only cause which can with certainty be traced to the state of the father's 
health. Many other morbid conditions of the blood also dispose to 
abortion. It has been observed to be a frequent result of lead-poisoning, 
also of the presence of noxious gases in the atmosphere, such as an 
excess of carbonic acid. 

Many causes act through the nervous system, such as fright, anxiety, 
sudden shock, and the like. Thus there are numerous instances on 
record in which women aborted suddenly after the receipt of some bad 
news, and it is said to have been of frequent occurrence in women im- 
mediately before execution. The influence of irritation propagated 
through the nervous system from a distance, tending to produce uterine 
contraction and abortion through the agency of reflex action, has been 
specially dwelt upon by Tyler Smith. Thus he points out that abortion 
not unfrequently occurs from the irritation of constant suckling in 
women who become pregnant during lactation. The effect of suckling 
in producing uterine contraction is, indeed, well known, and the appli- 
cation of the child to the breast for this purpose has long been recog- 
nized as a method of treatment in post-partum hemorrhage. The 
irritation of the trifacial in severe toothache; of the renal nerves in 
cases of gravel, in albuminuria, etc. ; of the intestinal nerves in exces- 
sive vomiting, in diarrhoea, obstinate constipation, ascarides, etc., all 
act in the same way. We may, perhaps, also explain by this hypotli- 



260 PREGNANCY. 

esis the fact that women are more apt to abort at what would have 
been the menstrual epoch than at other times, as the ovarian nerves 
may then be subject to undue excitement. It is probable, however, 
that there may be also at these times more or less active congestion of 
the decidua, which may predispose to laceration of its capillaries and 
blood extravasation. Such congestion exists in those exceptional cases 
in which menstruation continues for one or more periods after concep- 
tion, the blood probably escaping from the space between the decidua 
vera and reflexa ; and, therefore, there is no reason to question its also 
happening even when such abnormal menstruation is not present. 

Certain physical causes may produce abortion by separating the 
ovum. Thus it may follow a fall, a blow, or other accidents of a 
trivial character. On the other hand, women may be subjected to 
injuries of the severest kind without aborting. The probability, there- 
fore, is that these apparently trivial causes only operate in women who, 
for some other reason, are predisposed to the accident. This is borne 
out by the fact — which is well known in these days, when the artificial 
production of abortion is, unhappily, far from a very rare event — that 
it is by no means easy to destroy the vitality of the foetus. I myself 
know of a case in which the uterine sound was passed several times 
into a pregnant uterus without producing abortion, the pregnancy pro- 
ceeding to term. Oldham has related a similar case in which he in 
vain attempted to induce abortion by the sound in a case of contracted 
pelvis; and Duncan has mentioned an instance in which an intra- 
uterine stem pessary was unwittingly introduced and worn for some 
time by a pregnant woman without any bad effect. I have elsewhere 1 
narrated a remarkable case in which not only was the uterine sound 
passed, but in which several large pieces of decidua were subsequently 
expelled, and yet miscarriage did not occur. The fact that pregnancy 
is with difficulty interfered with when there is a healthy relation be- 
tween the ovum and the uterus, no doubt explains the disastrous effects 
of criminal abortion, which have been especially insisted on by many 
of our American brethren. 

Morbid states of the uterus have an important influence in the pro- 
duction of abortion. Any condition which mechanically interferes 
with the proper development of the uterus is apt to operate in this 
way. Amongst these may be mentioned fibroid tumors ; the presence 
of old peritoneal adhesions, rendering the womb a more or less fixed 
organ ; but, above all, flexion and displacement of the uterus. Eetro- 
flexion of the uterus is, unquestionably, one of the most frequent 
factors in its production, not only on account of the irritation which 
the abnormal position sets up, but from interference with the uterine 
circulation, which leads to the effusion of blood and the death of the 
ovum. An inflamed condition of the cervical and uterine mucous 
membranes will act in the same way should pregnancy have occurred, 
although such a condition more often prevents conception taking place. 

Symptoms. — One of the earliest indications of impending abortion is 
more or less hemorrhage. This may at first be slight, and may last for a 

1 Obstet. Trans., vol. xxi. p. 290. 



ABORTION AND PREMATURE LABOR. 261 

short time only, recurring after an interval of time, or it may commenee 
with a sudden and profuse discharge. Occasionally it is very abundant, 
and its continuance and amount form one of the gravest symptoms of 
the accident. After the loss of blood has continued for a greater or 
less length of time — it may be even for some days — uterine contrac- 
tions come on, recurring at regular intervals, and eventually lead to 
the expulsion of the ovum. More rarely the impending miscarriage 
commences with pains, which lead to laceration of vessels and hemor- 
rhage. 

As long as one or other of these symptoms exist alone, we may 
hope to avert the threatened miscarriage ; but when both occur together 
there is little or no chance of its being arrested. Certain premonitory 
symptoms are described by authors as common in abortion, such as 
feverishness, shivering, a sensation of coldness ; all of which are 
obscure and unreliable, and are certainly much more frequently absent 
than present. 

If the pregnancy be early it is probable that the entire ovum will 
be shed with little trouble, and it often passes unperceived in the clots 
which surround it. It is, therefore, of importance that all the dis- 
charges should be very carefully examined. After the second month 
the rigid aud undilated cervix presents a formidable obstacle to the 
escape of the ovum, and it may be a considerable time before there is 
sufficient dilatation to admit of its passage. This is gradually effected 
by the continuance of pains, but not without a severe loss of blood. 
It may be that the amnion is ruptured and the foetus expelled first. 
After a lapse of time the secundines are also shed, but there may be a 
considerable delay, amounting even to days, before this is effected. 
As long as any portions of the membranes are retained in utero, the 
patient is necessarily subjected to considerable risk, not only from the 
continuance of hemorrhage, but also from septicaemia. Hence it may 
be laid down as a rule that we can never consider our patient out of 
danger until we have satisfied ourselves that the whole of the uterine 
contents have been expelled. 

Treatment. — Our first endeavor in any case of impending miscar- 
riage will be, of course, to avert the threatened accident If hemor- 
rhage has not been excessive, and if, on vaginal examination — which 
should always be practised, with strict antiseptic precautions — we find 
no dilatation of the os, we may entertain a reasonable hope of success. 
If, on the contrary, we find the os beginning to open, if we are able to 
insert the finger through it so as to touch the ovum, especially if pains 
also exist, we are justified in considering abortion to be inevitable, and 
the indication will then be to have the ovum expelled, and the case 
terminated as soon as possible. In the former case the most absolute 
rest is the first thing to insist on. The patient should be placed in bed, 
not overburdened with clothes, in a cool temperature, and she should 
have a light and easily assimilated diet. All movements, even rising out 
of bed to empty the bladder or bowels, should be absolutely prohibited. 
To avert the tendency to the commencement of uterine contraction there 
is no remedy so useful as opium, which must be given freely and fre- 
quently repeated. It may be administered either in the form of 



262 PREGNANCY. 

laudanum or of Battley's sedative solution, which has the advantage 
of producing less general disturbance. It may be advantageously 
exhibited in doses of from twenty to thirty minims, and repeated after 
a few hours. A still better preparation is chlorodyne, which I have 
found of extreme value in arresting impending miscarriage, in doses of 
ten minims, repeated every third or fourth hour. If from any other 
cause it is considered inadvisable to give the sedative by the mouth, 
it may be administered in a small starch enema per rectum. In all 
cases it will be necessary to keep the patient more or less under the 
influence of the drug for several days, and until all symptoms of mis- 
carriage have passed away. Care should be taken that the bowels do 
not become locked up by the action of the opiates — as this might of 
itself be a cause of irritation — and their constipating effects ought to 
be obviated by small doses of castor oil, or other gentle aperient. 
Various subsidiary methods of treatment have been recommended, such 
as bleeding from the arm, or the local application of leeches in sup- 
posed plethoric states of the system ; revulsives, such as dry cupping to 
the loins ; the application of ice, to check hemorrhage ; astringents, such 
as acetate of lead or gallic acid, for the same purpose. Most of these, 
if not hurtful, will be at least useless. The cases in which venesection 
would be beneficial are extremely rare, and the local applications, espe- 
cially cold, are much more apt to favor than to prevent uterine action. 

In cases of repeated miscarriage in successive pregnancies, a special 
course of prophylactic treatment is indicated, and is often attended 
with much success. In cases of this kind the first indication, and one 
which ought to be carefully attended to, is to seek for, and, if possible, 
to remove or mitigate the cause which has given rise to the former 
abortions. Those causes which depend on constitutional states must 
first be carefully investigated, and treated according to the indications 
present. These may be obscure and not easily discovered ; but it is 
certainly unwise to assume too readily the existence of what has been 
called " a habit of abortion," which further inquiry may prove to be 
only an indication of constitutional debility, degeneracy of the placental 
structures, or a latent and unsuspected syphilitic taint. If constitu- 
tional debility be present to a marked extent, a generous diet and a 
restorative course of treatment (preparations of iron, quinine, and other 
suitable tonics) may effect the desired object. 

Local congestion of the uterus or a general plethoric state of the 
patient have often been supposed to be efficient causes of recurring 
abortion. Dr. Henry Bennet has especially dwelt on the influence of 
congestion and abrasions of the cervix in causing premature expulsion 
of the foetus, 1 and recommends the topical application of nitrate of 
silver or other caustics to the inflammatory abrasions existing on the 
neck of the womb. Formerly venesection was a favorite remedy ; and 
many authors have recommended the local abstraction of blood by 
leeches applied to the groin, or around the anus, or even to the cervix. 
The influence of general plethora is more than doubtful ; and although 
local congestions are, probably, much more effective causes, still it would 

1 On Inflammation of the Uterus, p. 432. 



ABORTION AND PREMATURE LABOR. 263 

seem more judicious to treat them by rest and local sedatives rather 
than by topical applications, which, injudiciously applied, might pro- 
duce the very accident they were intended to prevent. 

The position of the uterus should be carefully investigated. If it 
be found to be retroflexed, a well-fitting Hodge's pessary should be 
applied, so as to support it until it has completely risen out of the 
pelvis. 

The possibility of syphilitic infection should always be inquired 
into, for this poison may act on the product of conception long after 
all appreciable traces of it have disappeared from the infected parent. 
Should there be recurrent abortions in a patient who had formerly 
suffered from syphilis, or whose husband had at any time contracted 
the disease, no time should be lost in using appropriate anti-syphilitic 
remedies, which should invariably be administered both to the husband 
and wife. Didav especially insists that in such cases it is not sufficient 
to submit the father and mother to a mercurial course in the absence 
of pregnancy, but that, as each successive impregnation occurs, the 
mother should again commence anti-syphilitic treatment, even though 
she has no visible traces of the disease. 1 In this way there is reason- 
able ground for hoping that infection of the ovum may be prevented. 
I think, too, that we may be the more encouraged to persevere in the 
treatment of these unfortunate cases, from the fact that the syphilitic 
poison tends to wear itself out. I have seen several cases in which 
this taint at first produced early abortion, then each successive preg- 
nancy was of longer duration, until eventually a living child was born. 

In certain morbid states of the placenta, which act by preventing 
the proper nutrition of the foetus and the due aeration of its blood, 
there is no reliable means of treatment except the general improvement 
of the mother's health. Simpson strongly recommended the adminis- 
tration of chlorate of potash in cases in which the child habitually dies 
in the later months of pregnancy, on the supposition that it supplied to 
the blood a large amount of oxygen, and thus made up for any deficiency 
in the supply of that element through the placental tufts. The theory 
is, at best, a doubtful one, although I believe the drug to be unquestion- 
ably beneficial in cases of the kind. It probably acts by its tonic prop- 
erties rather than in the manner Simpson supposed. It may be given 
in doses of fifteen to twenty grains three times a day, and may be ad- 
vantageously combined with small doses of dilute hydrochloric acid. 
In frequently recurring premature labors with dead children, Simpson 
strongly recommended the induction of premature labor a little before 
the time at which we had reason to believe that the foetus had usually 
perished ; or, in other words, before the placental disease had advanced 
sufficiently far to interfere with its nutrition. The practice has con- 
stantly been adopted with success, and is perfectly legitimate, but the 
difficulty, of course, is to fix on the right time. Careful auscultation 
of the foetal heart may be of some use in guiding us to a decision, as 
the death of the foetus is generally preceded for some days by irregular, 
tumultuous, and intermittent action of the heart. 

i Diday : Infantile Sj-philis, Syd. Soc. Trans., p. 207. 



264 PREGNANCY. 

There will always remain a certain number of cases in which no 
appreciable cause can be discovered. Under such circumstances pro- 
longed rest, at least until the time has passed at which abortion 
formerly took place, will afford the best chance of avoiding a recur- 
rence of the accident. There must always be some difficulty in carry- 
ing out this indication, inasmuch as the patient's health is apt to suffer 
in other ways from the confinement, and the want of fresh air and 
exercise which it entails. The strictness with which rest should be 
insisted on must vary in different cases, but it should be specially 
attended to at what would have been the menstrual periods. At these 
times the patient should remain in bed altogether ; at others she may 
lie on a sofa, and, if circumstances permit, spend part of the day at 
least in the open air. Sexual intercourse should be prohibited. 
Should actual symptoms of abortion come on, the preventive treat- 
ment, already indicated, may be resorted to. Great care, however, 
should be used in prescribing opiates as preventives, and they should 
be given for a specified time only. I have seen, more than once, an 
incurable habit of opium-eating originate from the incautious and too 
long-continued exhibition of the drug in snch cases. 

When we have satisfied ourselves that abortion is inevitable, we 
must proceed to employ treatment that favors the expulsion of the 
ovum. 

If the os be sufficiently dilated, and the pains strong, we may find 
the ovum separated and protruding from the os. We may then be 
able to detach it by the finger. For this purpose the uterus is de- 
pressed from without by the left hand, while an endeavor is made to 
scoop out the ovum with the examining finger. If it be out of reach 
and yet appear detached, chloroform should be administered, the 
whole hand introduced into the vagina, and the finger into the uterine 
cavity. The complete detachment of the ovum can, in this way, be 
far more readily and safely effected than by using any of the many 
ovum forceps which have been invented for the purpose. 

If the ovum be not sufficiently separated or the os be undilated, 
means must be taken to control the hemorrhage until the former can 
be removed or expelled. It is here that plugging of the vagina finds 
its most useful application. This may be done in various ways. The 
best is to introduce a long strip of iodoform gauze about two inches in 
width, with which the vagina, which has been previously douched with 
1 in 1000 sublimate solution, is thoroughly packed, the lower end of 
the gauze hanging out of the vulva. This may be pulled out in from 
twelve to twenty-four hours. If the ovum is found to be detached, it 
may be removed ; if not, a fresh plug is introduced. Another plan is 
to soak a number of pledgets of cotton wool in carbolized water, and 
tie a string round each. The vagina can be completely and effectively 
packed with these ; and this is best done through a speculum, the patient 
being placed on her left side. Each pledget should be covered with 
glycerine and dusted with iodoform, which renders them sufficiently 
aseptic, but in no case should they be left in for more than eight to 
twelve hours. The pledgets can be withdrawn by the strings, but if 
these are not used, much pain is caused in getting them out of the 



ABORTION AND PREMATURE LABOR. 2G5 

vagina. Two or three full doses of the liquid extract of ergot, of 5ss 
to 5j each, or a subcutaueous injection of ergotine, may be given while 
the ping is in position. The plug itself is a strong excitant of uterine 
action, and the two combined often effect complete detachment ; so that, 
on removal of the tampon, the ovum may be found lying loose in the 
os uteri. If, after a sufficient time has been given, the os should 
remain undilated, it is necessary to open it up, and this is best done 
by anaesthetizing the patient, exposing the cervix with the duck-bill 
speculum, and dilating with Hegar's dilators. This can be thoroughly 
and effectually done in about an hour; but considerable experience and 
gynecological manipulations are required to use them satisfactorily. 
Laminaria or tupelo tents may be used, but I think a well-prepared 
sponge tent is preferable, and it can be maintained in situ by a vaginal 
plug below it. It also acts as a most efficient plug, effectually con- 
trolling all hemorrhage. In a few hours it generally opens up the os 
sufficiently to admit the finger. Previous to introduction it should be 
well dusted with iodoform. 

The most troublesome cases are those in which the fcetus is first 
expelled, and the placenta and membranes remain in utero. As long 
as this is the case the patient can never be considered safe from the 
occurrence of septicaemia. Dr. Priestley has strongly insisted on the 
importance of removing the secundines as soon as possible, and this is 
most easily accomplished after rapid dilatation with Hegar's dilators. 
There can be no doubt that this should be done whenever it is feasible. 
Cases, however, are frequently met with in which any forcible attempt 
at removal would be likely to prove very hurtful, and in which it is 
better practice to control hemorrhage by the plug or sponge tent, and 
wait until the placenta is detached, which it will generally be in a day 
or two at most. Under such circumstances fetor and decomposition 
of the secundines may be prevented by intra-uterine antiseptic injec- 
tions. Provided the os be sufficiently patulous to prevent the collec- 
tion of the fluid in the uterine cavity, and not more than a drachm or 
two of fluid be injected at a time, so as simply to wash away and 
disinfect decomposing detritus, they can be used with perfect safety. 
Sometimes cases are met with in which the os has entirely closed, and 
in which we can only suspect the retention of the placenta by the his- 
tory of the case, the continuance of hemorrhage, or the presence of a 
fetid discharge. Should we see reason to suspect this, the os must be 
dilated and the uterine cavity thoroughly explored under chloroform, 
and any retained products removed by the finger; and then it is often 
advieable to scrape the endometrium with a curette, so as to remove 
any shreds that may be attached to it. Subsequently it may be 
swabbed with cotton-wool saturated in liquor iodi. This condition 
of things is far from uncommon in women who have not had medical 
assistance from the first, and it often gives rise to very troublesome and 
anxious symptoms. It has been said that placenta? thus retained have 
been completely absorbed, and cases of the kind have been related by 
Naegele and Osiander. The spontaneous absorption, however, of so 
highly organized a body as the placenta would be a phenomenon of 
the most remarkable character ; and it seems more natural to suppose 



266 PREGNANCY. 

that, in most cases of the kind, the placenta has been cast off without 
the knowledge of the patient. Sometimes the placenta never becomes 
entirely detached, and, retaining organic connection with the uterine 
walls, forms what has been called a u placental polypus" This may 
produce secondary hemorrhages, in the same way as an ordinary fibroid 
polypus. Barnes recommends the removal of these masses by means of 
the wire eeraseur. Before their detection the os uteri must be opened up. 

Retention in Utero of a Blighted Ovum. — The cases previously 
alluded to, in which an ovum has perished in early pregnancy and is 
retained in utero, are often puzzling and may give rise to serious moral 
and medico-legal questions. The blighted ovum may be retained for 
many months, the outside limit, according to McClintock, 1 by whom 
the subject has been ably discussed, being nine months. The appear- 
ance of the ovum when thrown oft will give no reliable clue to the 
length of time which has elapsed since it perished, but careful examina- 
tion of microscopic sections will enable an expert to observe the degen- 
erative changes which have occurred in products long retained in utero, 
and so to distinguish them with certainty from those of recent origin. 
The symptoms are often very obscure. Generally there have been the 
usual indications of pregnancy which, with or without signs of impend- 
ing miscarriage, disappear or are modified, and then follows a period of 
ill-health, with pelvic uneasiness, and irregular metrorrhagia, which 
may be mistaken for menstruation. Occasionally, but by no means 
necessarily, there is a fetid discharge, and this probably exists only 
when the membranes have broken, and air has access to the ovum. In 
some cases obscure septicemic symptoms have been observed. Such 
symptoms are obviously too indefinite to lead to an accurate diagnosis. 
In the course of time the ovum is generally thrown off, with more or 
less hemorrhage. If the nature of the case is detected, ergot may be 
given to promote the expulsion of the uterine contents, and it may even 
be advisable to dilate the cervix and remove them artificially. 

Eden 2 has recently directed attention to a curious and little studied 
condition to which he gives the name ot spurious abortion. These 
cases " mimic abortion in the occurrence of a period of amenorrhoea 
with enlargement of the uterus, and the formation within it of a body, 
the detachment and explusion of which is followed by a return to 
menstrual regularity, and the former condition of general health. The 
body expelled is not an ovum, but is formed entirely of maternal 
structures." I have no recollection of having myself seen a case of 
this kind, but it is obviously of importance to decide its exact nature, 
as such an occurrence might give rise to serious questions of a medico- 
legal character, involving the chastity of the patient. It might be due 
to the presence of a fertilized ovum which has perished in the first 
fortnight of pregnancy, and left no trace of its existence, leaving the 
decidual changes to progress. On the other hand, it is a theoretical 
possibility that some other stimulus than pregnancy may set up a 
growth of decidua, and arrest menstruation. It will be very important 
to settle whether the latter can or cannot occur, but at present we are 

1 Sydenham Society's edition of Smellie's Midwifery, vol. i. p. 169. 

2 Brit. Med. Journ., Nov. 20, 1897. 



ABORTION AND PREMATURE LABOR. 267 

not in possession of sufficient facts to decide the question. The detec- 
tion of chorionic villi would, of course, clear up any doubt as to the 
previous existence of pregnancy. 

Subsequent Management of Abortion. — The frequency with 
which abortion leads to chronic uterine disease should lead us to attach 
much more importance to the subsequent management of the patient 
than has been customary. The usual practice is to confine the patient 
to bed for two or three days only, and then to allow her to resume her 
ordinary vocations, on the supposition that a miscarriage requires less 
subsequent care than a confinement. The contrary of this is, however, 
most probably the case ; for the uterus has been emptied when it is 
unprepared for involution, and that process is often very imperfectly 
performed. We should, therefore, insist on at least as much attention 
being paid to rest as after labor at term. 



PART IIL 

LABOR. 
CHAPTER I c 

THE PHENOMENA OF LABOR. 

Delivery at Term. — In considering delivery at term we have to 
discuss two distinct classes of events. 

One of these is the series of vital actions brought into play in order 
to eifect the expulsion of the child ; and the other consists of the move- 
ments- imparted to the child — the body to be expelled — in other words, 
the mechanism of delivery. 

Causes of Labor. — Before proceeding to the consideration of these 
important topics, a few words may be said as to the determining causes 
of labor. This subject has been from the earliest times a qucestio vexata 
among physiologists ; and many and various are the theories which 
have been broached to explain the curious fact that labor sponta- 
neously commences, if not at a fixed epoch, at any rate approximately 
so. It must be admitted that even yet there is no explanation which 
can be implicitly accepted. 

The explanations which have been given may be divided into two 
classes — those which attribute the advent of labor to the foetus, and 
those which refer it to some change connected with the maternal gen- 
erative organs. 

The former is the opinion which was held by the older accoucheurs, 
who assigned to the foetus some active influence in effecting its own 
expulsion. It need hardly be said that such fanciful views have no 
kind of physiological basis. Others have supposed that there might 
be some change in the placental circulation, or in the vascular system 
of the foetus, which might solve the mystery. 

The majority of obstetricians, however, refer the advent of labor to 
purely maternal causes. Among the more favorite theories is one, 
which was originally started by Dr. Power, and adopted and illustrated 
268 



THE PHENOMENA OF LABOR. 269 

by Depaul, Dubois, and other writers. It is based on the assumption 
that there is a sphincter action of the fibres of the cervix, analogous to 
that of the sphincters of the bladder and rectum, and that when the cervix 
is taken up into the general uterine cavity as pregnancy advances, the 
ovum presses upon it, irritates its nerves, and so sets up reflex action, 
which ends in the establishment of uterine contraction . This theory 
was founded on erroneous conceptions of the changes that occurred in 
the neck of the uterus ; and, as it is certain that obliteration of the 
cervix does not really take place in the manner that Power believed 
when his theory was broached, it is obvious that its supposed result 
cannot follow. A modification of this theory is that held by Stoltz 
and Bandl. According to this view, when the cervix softens during 
the last weeks of pregnancy, the painless uteriue contractions of gesta- 
tion act upon the os internum, and open it sufficiently to admit of the 
ovum pressing on the lower segment of the uterus, and so inducing 
labor. 

Girin 1 contends that the descent and pressure of the foetal head on 
the os internum is favored by changes in the density of the liquor 
amnii. This attains its maximum density in the early months of 
pregnancy, when it is 1.030, and it diminishes steadily until term, 
when it is nearly that of water. The specific gravity of the foetus is 
at first lower than that of the amniotic fluid, but becomes steadily 
higher. Eventually the foetus, sinking on the os internum, excites the 
uterus to contraction. 

Extreme distention of the uterus has been held to be the determining 
cause of labor, a view lately revived by Dr. King, of Washington, 2 who 
believes that contractions are induced because the uterus ceases to aug- 
ment in capacity, while its contents still continue to increase. This 
hypothesis is sufficiently disproved by a number of clinical facts which 
show that the uterus may be subject to excessive and even rapid dis- 
tention — as in cases of hydramnios, multiple pregnancy, and hydatidi- 
form degeneration of the ovum — without the supervention of uterine 
contractions. 

Spiegelberg 3 attributes the advent of labor to some substance, the 
nature of which he does not define, accumulating in the maternal blood 
toward the end of pregnancy, which is used for the development of the 
foetus, and which, when no longer required for that purpose, irritates 
the uterine nerve centres, and so produces the increased uteriue con- 
tractions of true labor. This seems to be a pure hypothesis, not based 
on any evidence. 

Another inciter of uterine action has been supposed to be the sepa- 
ration of the ovum from its connection to the uterine parietes, in 
consequence of fatty degeneration of the decidua occurring at the end 
of pregnancy. The supposed result of this change, which undoubtedly 
occurs, is that the ovum becomes so detached from its organic adhe- 
sions as to be somewhat in the position of a foreign body, and thus 
iucites the nerves so largely distributed over the interior of the uterus. 

i Arch, de Tocologie, No. 8, 1889. 

2 American Journal of Obstelricts, vol. lil. p. 561. 

s Spiegelberg : Text book of Midwifery. Syd. Soc. Trans., vol. i. p. 172. 



270 LABOE. 

This theory, which has been widely accepted, was originally started by 
Sir James Simpson, who pointed out that some of the most efficient 
means of inducing labor (such, for example, as the insertion of a gum- 
elastic catheter between the ovum and the uterine walls) probably act 
in the same way, viz., by effecting separation of the membranes and 
detachment of the ovum. 

Barnes instances, in opposition to this idea, the fact that ineffectual 
attempts at labor come on at the natural term of gestation in cases of 
extra-uterine pregnancy, when the foetus is altogether independent of 
the uterus, and, therefore, he argues, the cause cannot be situated in 
the uterus itself. A fair answer to this argument would be that 
although, in such cases, the womb does not contain the ovum, it does 
contain a decidua, the degeneration and separation of which might suf- 
fice to induce the abortive and partial attempts at labor then witnessed. 

Leopold 1 suggests that the advent of labor may be connected with 
other changes in the decidua which occur in advanced pregnancy. He 
points out that then giant cells, containing many nuclei, appear in the 
serotina which penetrate the uterine sinuses, and cause the formation 
in them of thrombi. The obstruction in the calibre of a number of 
these vessels leads to a stasis of the maternal blood returning from the 
placenta, and to an increase of carbonic acid in it, which may excite 
the motor centre for uterine contraction, which is known to exist in 
the medulla oblongata. 

Objections to These Theories. — A serious objection to all these 
theories, which are based on the assumption that some local irritation 
brings on contraction, is the fact, which has not been generally appre- 
ciated, that uterine contractions are always present during pregnancy 
as a normal occurrence, and that they may be, and often are, readily 
intensified at any time, so as to result in premature delivery. 

It is, indeed, most likely that, at or about the full term, the nervous 
supply of the uterus is so highly developed, and in so advanced a state 
of irritability, that it more readily responds to stimuli than at other 
times. If, by separation of the decidua, or in some other way, stimu- 
lation of the excitor nerves is then effected, more frequent and forcible 
contractions than usual may result, and, as they become stronger and 
more regular, terminate in labor. But, allowing this, it still remains 
quite unexplained why this should occur with such regularity at a 
definite time. 

Tyler Smith tried, indeed, to prove that labor came on naturally at 
what would have been a menstrual epoch, the congestion attending the 
menstrual nisus acting as the exciter of uterine contraction. He 
therefore refers the onset of labor to ovarian, rather than to uterine, 
causes. Although this view is upheld with all its author's great 
talent, there are several objections to it difficult to overcome. Thus, 
it assumes that the periodic changes in the ovary continue during 
pregnancy, of which there is no proof. Indeed, there is good reason 
to believe that ovulation is suspended during gestation, and with it, of* 
course, the menstrual nisus. Besides, as has been well objected to by 

1 " Studien liber die Schleimhaut," etc. Arch. f. Gyn., Bd. xi. s. 443. 



THE PHENOMENA OF LABOR. 271 

Cazeaux, even if this theory were admitted, it would still leave the 
mystery unsolved, for it would not explain why the menstrual nisus 
should act in this way at the tenth menstrual epoch, rather than at the 
ninth or eleventh. 

In spite, then, of many theories at our disposal, it is to be feared 
that we must admit ourselves to be still in entire ignorance of the 
reason why labor should come on at a fixed epoch. 

Mode in which the Expulsion of the Child is Effected. — The 
expulsion of the child is eifected by the contractions of the muscular 
fibres of the uterus, aided by those of some of the abdominal muscles. 
These efforts are in the main entirely independent of volition. So far 
as regards the uterine contractions, this is absolutely true, for the 
mother has no power of originating, lessening, or increasing the action 
of the uterus. As regards the abdominal muscles, however, the mother 
is certainly able to bring them into action, and to increase their power 
by voluntary efforts ; but, as labor advances, and as the head passes 
into the vagina and irritates the nerves supplying it, the abdominal 
muscles are often stimulated to contract, through the influence of reflex 
action, independently of volition on the part of the mother. 

There can be little doubt that the chief agent in the expulsion of the 
child is the contraction of the uterus itself. This opinion is almost 
unanimously held by accoucheurs, and the influence of the abdominal 
muscles is believed to be purely accessory Dr. Haughton, 1 however, 
maintains a view which is directly contrary to this. From an ex- 
amination of the force of the uterine contractions, arrived at by 
measuring the amount of muscular fibre contained in the walls of the 
uterus, he arrives at the conclusion that the uterine contractions are 
chieflv influential in rupturing the membranes, and dilating the os 
uteri, bringing into action, if needful, a force equivalent to 54 pounds ; 
but when this is effected, and the second stage of labor has commenced, 
he thinks the remainder of the labor is mainly completed by the con- 
tractions of the abdominal muscles, to which he attributes enormous 
powers, equivalent, if needful, to a pressure of 523.65 pounds on the 
area of the pelvic canal. 

These views bear on a topic of primary consequence in the physi- 
ology of labor. They have been fully criticised by Duncan, who has 
devoted much experimental research to the study of the powers brought 
into action in the expulsion of the child. His conclusions are that, so 
far from the enormous force being employed that Haughton estimated, 
in the large majority of cases the effective force brought to bear on the 
child by the combined action of both the uterine and abdominal mus- 
cles is less than 50 pounds — that is, less than the force which Haughton 
attributed to the uterus alone. In extremely severe labors, when the 
resistance is excessive, he thinks that extra power may be employed , 
but he estimates the maximum as not above 80 pounds, including in this 
total the action of both the uterine and abdominal muscles. Joulin 
arrived at the conclusion that the uterine contractions were capable of 
resisting a maximum force of about one hundredweight. Both these 

1 " On the Muscular Forces Employed in Parturition," etc. Dublin Quart. Journ. Med. Sc, vol. 
xlix. p. 459. 



272 LABOR. 

estimates, it will be observed, are much under that of Haughton, which 
Duncan describes as representing " a strain to which the maternal 
machinery could not be subjected without instantaneous and utter 
destruction." 

There are many facts in the history of parturition which make it 
certain that the chief factor in the expulsion of the child is the uterus. 
Among these may be mentioned occasional cases in which the action of 
the abdominal muscles is materially lessened, if not annulled — as in 
profound anaesthesia, and in some cases of paraplegia — in which, 
nevertheless, uterine contractions suffice to effect delivery. The most 
familiar example of its influence, however, and one that is a matter of 
everyday observation in practice, is when inertia of the uterus exists. 
In such cases no effort on the part of the mother, no amount of 
voluntary action that she can bring to bear on the child, has any 
appreciable influence on the progress of the labor, which remains in 
abeyance until the defective uterine action is re-established, or until 
artificial aid is given. 

Contraction of the uterus, then, being the main agent in delivery, it 
is important for us to appreciate its mode of action, and its effect on 
the ovum. 

Uterine Contractions at the Commencement of Labor. — We 
have seen that intermittent and generally painless uterine contractions 
exist during pregnancy. As the period for delivery approaches, these 
become more frequent and intense, until labor actually commences, 
when they begin to be sufficiently developed to effect the opening up 
of the os uteri, with a view to the passage of the child. They are now 
accompanied by pain, which increases as labor advances, and is so 
characteristic that " pains " are universally used as a descriptive term 
for the contractions themselves. It does not necessarily follow that 
uterine contractions are painless until they commence to effect dilata- 
tion of the os uteri. On the contrary, during the last days or even 
weeks of pregnancy, women constantly have irregular contractions, 
accompanied by severe suffering, which, however, pass off without pro- 
ducing any marked effect on the cervix. When labor has actually 
begun, if the hand is placed on the uterus, when a pain commences, 
the contraction of its muscular tissue is very apparent, and the whole 
organ is observed to become tense and hard, the rigidity increasing 
until the pain has reached its acme, the uterine walls then relaxing, 
and remaining soft until the next pain comes on. At the commence- 
ment of labor these pains are few, separated from each other by a con- 
siderable interval, and of short duration. In a perfectly typical labor 
the interval between the pains becomes shorter and shorter, while, at 
the same time, the duration of each pain is increased. At first they 
may occur only once in an hour or more, while eventually there may 
not be more than a few minutes' interval between them. 

If, when the pains are fairly established, a vaginal examination be 
made, the os uteri will be found to be thinned and dilated in jn-opor- 
tion to the progress of the labor. During the contraction the bag of 
membranes will be felt to bulge, to become tense from the downward 
pressure of the liquor amnii within it, and to protrude through the 



PLATE III 



Pancreas 



Stomach 



. Cceliac A. 

Sup. Mesent. A. 
V. Porta 




Int. Os Uteri 



Bladder 



Ext. Os Uteri 



Urethra 



Ext. Os Uteri 



Rectum 



Liquor Amnii 



Section of a Frozen Body at the Termination of the First 

Stage of Labor. (After Braune.) 

The bag of membranes is still unbroken, the cervix is fully 

dilated, and the head (in the second position) 

is in the pelvic cavity. 



THE PHENOMENA OF LABOR. 273 

08 if it be sufficiently open. The membranes, with the contained 
liquor amnii, thus form a fluid Avedge, which has a most important 
influence in dilating the os uteri (see Plate III). This does not, 
however, form the sole mechanism by which the os uteri is dilated, for 
it is also acted upon by the contractions of the muscular fibres of the 
uterus, which tend to pull it open. It is probable that the muscular 
dilatation of the os is effected chiefly by the longitudinal fibres, which, 
as they shorten, act upon the os uteri, the part where there is least 
resistance. 

Partly then by muscular contraction, partly by mechanical pressure, 
the cervical canal is dilated, and as it opens up it becomes thinner and 
thinner, until it is entirely taken up into the uterine cavity. 

There is no longer any obstacle to the passage of the presenting part 
of the child into the cavity of the pelvis, and the force of the pains 
now generally effects the rupture of the membranes, and the escape of 
the liquor amnii. There is often observed, at this time, a temporary 
relaxation in the frequency of the pains, which had been steadily 
increasing ; but they soon recommence with increased vigor. If the 
abdomen be now examined, it will be observed to be much diminished 
in size, partly in consequence of the escape of the liquor amnii, partly 
from the descent of the foetus into the pelvic cavity. 

The character of the pains soon changes. They become stronger, 
longer in duration, separated by a shorter interval, and accompanied 
by a distinct forcing effort, being generally described as " the bearing 
down" pains. Kow is the time at which the accessory muscles of 
parturition come into operation. The patient brings them into play in 
the manner which will be subsequently described, and the combined 
action of the uterine and abdominal muscles continues until the expul- 
sion of the child is effected. 

The precise mode of uterine contraction is still somewhat a matter 
of dispute. It is generally described as commencing in the cervix, 
passing gradually upward by peristaltic action, the wave then returning 
downward toward the os uteri. This view was maintained by Wigand, 
and has been indorsed by Pigby, Tyler Smith, and many other writers. 
In support of it they instance the fact that, on the accession of a pain, 
the presenting part first recedes, the bag of membranes then becomes 
tense and protrudes through the os, and it is not until some time that 
the presenting part of the child itself is pushed down. It is very 
doubtful if this view is correct ; and a careful examination of the course 
of the pains would rather lead to the belief that the contractions com- 
mence at the fundus, where the muscular tissue is most largely de- 
veloped, and gradually proceed downward to the cervix, the waves of 
contraction being, however, so rapid that the whole organ seems to 
harden en masse. The apparent recession of the presenting part, and 
the bulging of the bag of membranes, are certainly no proof that the 
contractions begin at the cervix ; for the commencing contraction would 
necessarily push down the fluid in front of the head, and cause the 
membranes to bulge, and the os to become tense, before its force was 
brought to bear on the foetus itself. Indeed, did the contraction com- 
mence at the lower part of the uterus, Ave should expect the opposite of 

18 



274 LABOR. 

what takes place to occur, and the waters to be pushed upward, 
aud away from the cervix. The fundal origin of the contraction is 
further illustrated by what is observed when the hand of the accoucheur 
is placed in the uterine cavity, as often happens in certain cases of hem- 
orrhage or turning ; for if a pain then comes on, it will be felt to start 
at the fundus, and gradually compress the hand from above downward. 

Value of the Intermittent Character of the Pains. — The inter- 
mittent character of the contractions is of great practical importance. 
Were they continuous, not only would the muscular powers of the 
patient be rapidly exhausted, but by the obliteration of the vessels 
produced by the muscular contraction, the circulation through the 
placenta would be interfered with, and the life of the child imperilled. 
Hence one of the chief dangers of protracted labor, especially after the 
escape of the liquor amnii, is that the uterine fibres may enter into a 
state of tonic rigidity, a condition that cannot be long continued with- 
out serious risks both to the mother and child. 

The fact that the uterine contractions are altogether involuntary 
proves them to be excited — as indeed, we would a priori infer from our 
knowledge of the anatomical arrangement of the nerves of the uterus — 
solely by the sympathetic system. Still it is a fact of everyday obser- 
vation that they can be largely influenced by emotions. Various 
stimuli applied to the spinal system of nerves (as, for example, when 
the mammae are irritated) have also a marked effect in inducing uterine 
contraction. The precise mode in which such influence is conveyed to 
the uterus, in spite of the numerous experiments which have been 
made for the purpose of determining how far labor is affected by 
destruction of the spinal cord, is still a matter of doubt. After the 
foetus has passed through the cervix, the spinal nerves distributed to 
the vagina and perineum are excited by the pressure of the pre- 
senting part, and through them the accessory powers of parturition are 
chiefly brought into play. The contraction of the muscles of the 
vagina itself is supposed to have some influence in favoring the ex- 
pulsion of the foetus after the birth of part of the body, and also in 
promoting the expulsion of the placenta. In the lower animals the 
vagina has a very marked contractile property, and is, in some of them, 
the main agent by which the young are expelled. In the human 
subject this influence is certainly of very secondary importance. 

Character and Sources of Pains During" Labor. — The amount of 
suffering experienced during labor varies much in different cases, and 
is in direct proportion to the nervous susceptibility of the patient. 
There are some women who go through labor with little or no pain at 
all. This is proved by the cases (of which there are numerous authentic 
instances recorded) in which labor has commenced during sleep, and 
the child has been actually born without the mother awakening. I am 
acquainted with a lady, who has had a large family, who assures me 
that, though labor is accompanied by a sense of pressure and dis- 
comfort, she experiences nothing which can be called actual pain. Such 
a happy state of affairs is, however, extremely exceptional, and, in the 
vast majority of cases, parturition is accompanied by intense suffering 



THE PHENOMENA OF LABOR. 275 

during its Avhole course, in some cases amounting to anguish which has 
probably no parallel under any other condition. 

The precise cause of the pain has been much discussed, and is, no 
doubt, complex. 

In the early stage of labor, and before the dilatation of the os, it is 
chiefly seated in the back, from whence it shoots around the loins and 
down the thighs. It is then probably produced, partly by pressure 
on the nerve-filaments caused by contraction of the muscular fibres to 
which they are distributed, and partly by stretching and dilatation of 
the muscular tissue of the cervix. M. Beau believes that in this stage 
the pain is not produced, strictly speaking, in the uterus itself, but is 
rather a neuralgia of the lumbo-abdominal nerves. The pains at this 
time are generally described as " acute " and " grinding," terms which 
sufficiently well express their nature. In highly nervous women these 
pains are often much less well borne than those of a later stage, and 
the suffering thev undergo is indicated by their extreme restlessness 
and loud cries as each contraction supervenes. As the os dilates, and 
the labor advances into the expulsive stage, other sources of suffering 
are added. 

The presenting part now passes into the vagina and presses on the 
vaginal nerves, as well as on the large nervous plexuses lying in the 
pelvis. As it descends lower it stretches the perineum and vulva, and 
presses on the bladder and rectum. Hence cramps are produced in 
the muscles supplied by the nerve plexuses, as well as an intolerable 
sense of tearing and stretching in the vulva and perineum, and often 
a distressing feeling of tenesmus in the bowels. By this time the 
accessory muscles of parturition are brought into action, and they, as 
well as the uterine muscles, are thrown into frequent and violent con- 
tractions, which, independently of the other causes mentioned, are 
sufficient of themselves to produce great pain, likened to that of colic, 
produced by involuntary and repeated contraction of the muscles of 
the intestines. 

Taking all these causes into consideration, there is no lack of suffi- 
cient explanation of the intolerable suffering which is so constant an 
accompaniment of childbirth. 

Effect of the Pains on the Mother and Foetus. — The effect of the 
pains on the mother's circulation is well marked. The rapidity of the 
pulse increases distinctly with each contraction, and, as the pain passes 
off, it again declines to its former state. A similar observation lias 
been made with regard to the sounds of the foetal heart, especially after 
the expulsion of the liquor amnii. Hicks has pointed out that during 
a pain the muscular vibrations give rise to a sound which often 
resembles that of the fcetal heart, and which completely disappears 
when the muscular tissue relaxes. The effect of the pain in intensi- 
fying the uterine souffle has been already mentioned. The strong 
muscular efforts would naturally lead ns to expect a marked elevation 
of temperature during labor. Further observations on this point are 
required; but Squire asserts that there is generally only a very slight 
increase in temperature during delivery, rapidly passing off as soon as 
labor is over. 



276 LABOR. 

Such being the physiological facts in connection with the labor pains, 
we may now describe the ordinary progress of a natural labor — that 
is, one terminated by the natural powers and with a head presenting. 

Division of Labor into Stages. — For facility of description obste- 
tricians have long been in the habit of dividing the course of labor into 
stages, which correspond pretty accurately with the natural sequence 
of events. For this purpose we generally talk of three stages : viz. (1) 
from the commencement of regular pains until the complete dilatation 
of the cervix {stage of effacement and dilatation) ; (2) from the com- 
plete dilatation of the cervix until the expulsion of the child (stage oj 
expulsion) ; (3) the concluding stage, comprising the permanent con- 
traction of the uterus, and the separation and expulsion of the placenta 
(stage of the after-birth). To these we may conveniently add a pre- 
paratory stage, antecedent to the regular commencement of the labor. 

Preparatory Stage. — For a short time before delivery, varying 
from a few days to a week or two, certain premonitory symptoms 
generally exist, which indicate the approaching advent of labor. Some- 
times they are well marked, and cannot be mistaken : at others they 
are so slight as to escape observation. Amongst the most common is 
a sinking of the uterus into the pelvic cavity, resulting from the relax- 
ation of the soft parts preceeding delivery. The result is that the 
upper edge of the uterine tumor is less high than before, and in con- 
sequence the pressure on the respiratory organs is diminished, and 
the woman often feels lighter and altogether less unwieldy than in 
the previous weeks, if a vaginal examination be made at this time, 
the lower segment of the uterus will be found to have sunk lower into 
the pelvic cavity ; and the consequence of this is that, while the respira- 
tion is less embarrassed and the patient feels less bulky, other accom- 
paniments of pregnancy, such as hemorrhoids, irritability of the 
bladder and bowels, and oedema of the limbs, become aggravated. 
The increased pressure on the bowels often induces a sort of temporary 
diarrhoea, which is so far advantageous that it empties the bowels of 
feces which may have collected within them. As has already been 
pointed out, the contractions which have been going on at intervals 
during the latter months of pregnancy now get more and more marked, 
and they have the effect of producing a real shortening of the cervix, 
which is of great value preparatory to its dilatation. More marked 
mucous discharge from the cavity of the cervix also generally occurs 
a short time before labor, and it is not infrequently tinged with blood 
from the laceration of minute capillary vessels. The discharge, popu- 
larly known as the " shows" is a pretty sure sign that labor is not far 
off. It may, however, be entirely absent, even until the birth of the 
child. When copious, it serves to lubricate the passages, and is 
generally coincident with rapid dilatation of the parts and a speedy 
labor. 

During this time (premonitory stage) painful uterine contractions are 
often present, which, however, have no effect in dilating the cervix. 
In some cases they are frequent and severe, and are very apt to be 
mistaken for the commencement of real labor. Such u false pains" as 
they are termed, are often excited and kept up by local irritations, 



THE PHENOMENA OF LABOR. 277 

such as a loaded or disordered state of the intestinal canal ; and they 
frequently give rise to considerable distress, and much inconvenience 
both to the patient and practitioner. They are, it should be remem- 
bered, only the normal contractions of the uterus intensified and accom- 
panied with pain. 

First Stage, or Dilatation. — As labor actually commences, the 
uterine contractions become stronger, and the fact that they are "true" 
paius can be ascertained by their etfect on the cervix. If a vaginal 
examination be made during one of these, the membranes will be felt 
to become tense and bulging during the pain, and the os uteri will be 
found partially dilated, and thinned at its edges. As labor advances 
this effect on the os becomes more and more marked. At first the 
dilatation is very slight, perhaps not more than enough to admit the 
tip of the examining finger, and both the upper and lower orifices of 
the cervix can be made out. As the pains get stronger and more fre- 
quent, dilatation proceeds in the way already described, and the cervix 
gets more thin and tense, until we can feel a thin circular ring (which 
is lax between the pains, but becomes rigid and tense during the 
contraction when the bag of waters bulges through it), without any 
distinction between the upper and lower orifices. During this time 
the patient, although she may be suffering acutely, is generally able 
to sit up and walk about. The amount of pain experienced varies 
much according to the character of the patient. In emotional women 
of highly developed nervous susceptibilities it is generally very great. 
They are restless, irritable, and desponding, and when the pain comes 
on cry out loudly. The character of the cry is peculiar and well 
marked during the first stage, and has constantly been described by 
obstetric writers as characteristic. It is acute and high, and is cer- 
tainly very different from the deep groans of the second stage, when 
the breath is involuntarily retained to assist the parturient effort. 
When dilatation is nearly completed various reflex nervous phenomena 
often show themselves. One of these is nausea and vomiting, another 
is uncontrollable shivering, which is not accompanied by a sense of 
coldness, the patient being often hot and perspiring. Both these 
symptoms indicate that the propulsive stage will shortly commence ; 
and they may be regarded as favorable rather than otherwise, although 
they are apt to alarm the patient and her friends. By this time the 
os is fully dilated, the membranes generally rupture spontaneously, and 
a considerable portion of the liquor amnii flows away. The head, if 
presenting, often acts as a sort of ball-valve, and, falling down on 
the aperture of the cervix, prevents the complete evacuation of the 
liquor amnii, which escapes by degrees during the rest of the labor, 
or mav be retained in considerable quantity until the birth of the 
child. * 

It not infrequently happens, if the membranes are somewhat tougher 
than usual and the pains frequent and strong, that the fcetus is pushed 
through the pelvis, and even expelled surrounded by the membranes. 
When this occurs the child is said to be born with a u caul," and this 
event would doubtless happen more frequently than it does were it not 
the custom of the accoucheur to rupture the membranes artificially as 



278 LABOR. 

soon as the os is completely opened up, after which time their integrity 
is no longer of any value. 

Second Stage, or Propulsion. — The os is now entirely retracted 
over the presenting part, and is no longer to be felt, the vagina and 
the uterine cavity forming a single canal. I^ow the mucous discharge 
is generally abundant, so that the examining finger brings away long 
strings of glairy, transparent mucus tinged with blood. The pains, 
after a short interval of rest, become entirely altered in character. 
The uterus contracts tightly round the foetus, the presenting part 
descends into the pelvis, and the true propulsive pains commence. 
The accessory muscles of parturition now come into play. With each 
pain the patient takes a deep inspiration, and thus fills the chest so as 
to give a 'point d'appui to the abdominal muscles. For the same 
reason she involuntarily seizes hold of some point of support, as the 
hand of a bystander or a towel tied to the bed, and, at the same time, 
pushes with her feet against the end of the bed, and so is able to bear 
down to advantage. The cries are no longer sharp and loud, but 
consist of a series of deep suppressed groans, which correspond to a 
succession of short expirations made during the straining effort. In 
this way the abdominal muscles contract forcibly on the uterus, which 
they further stimulate to action by pressing upon it. It is to be 
observed that these straining efforts are, to a considerable extent, under 
the control of the patient. By encouraging her to hold her breath 
and bear down they can be intensified ; while if we wish to lessen 
them we can advise her to call out, and when she does so the abdom- 
inal muscles have no longer a fixed point of action. Although the 
patient may thus lessen the effect of these accessory muscles, it is 
entirely out of her power to stop their action altogether. As labor 
advances the head descends lower and lower, receding somewhat in the 
intervals between the pains, until eventually it comes down on the 
perineum, which it soon distends. 

The pains now get stronger and more frequent, often with scarcely 
a perceptible interval between them, until the perineum gets stretched 
by the advancing head. In the interval between the pains the elas- 
ticity of the perineal structures pushes the head upward, so as to 
diminish the tension to which the perineum is subjected, the next pain 
again putting it on the stretch and protruding the head a little further 
than before. By this alternate advance and recession the gradual 
yielding of the structures is favored and risk of laceration greatly 
diminished. During this time the pressure of the head mechanically 
empties the bowel of its contents. During the last pains, when the 
perineum is stretched to the utmost, the anal aperture is dilated, some- 
times to the size of a silver dollar; and in this way the perineum is 
relaxed, just as the distention and consequent risk of laceration are at 
their maximum. The apex of the head now protrudes more and more 
through the vulva, surrounded by the orifice of the vagina, and eventu- 
ally it glides over the perineum and is expelled. (See Plate IV.) 
The intensity of the suffering at this moment generally causes the 
patient to call out loudly. The force of the abdominal muscles is thus 
lessened at the last moment, and this, in combination with the relaxa- 



PLATE IV. 



Eetraction ring 



Promontory of 
sacrum 



Os externum 



Posterior vaginal wall 




Placenta 



etraction ring 



Utero-vesical 
peritoneum 
Bladder 



Os externum 
Urethra 

Anterior vaginal 
wall 



*^> Caput Succedaneum 
Vulva 
Blood effusion in perineum 



Section of a Frozen Body towards the Termination of the Second 

Stage of Labor. (After Barbour.) The head is beginning to 

distend the vulva, the anus being greatly stretched, 

and there is a well marked Caput Succedaneum. 



THE PHENOMENA OF LABOR, 



279 



tiou of the sphincter ani, forms an admirable contrivance for lessening 
the risk of perineal injury. The rest of the body is generally expelled 
immediately by a single paiu, and with it are dischaged the remains of 
the liquor amnii, and some blood-clots from separation of the placenta ; 
and so the second stage of labor terminates. 

The Third Stage. — The third stage commences after the expulsion 
of the child. It is of paramount importance to the safety of the 
mother that it should be conducted in a natural and efficient manner ; 
for it is now that the uterine sinuses are closed, and the frail barrier 
by which nature effects this may be very readily interfered with, and 
serious and even fatal loss of blood ensue. Unfortunately, it is too 
often the case that the practitioner's entire attention is fixed on the 
expulsion of the child, so that the natural history of the rest of delivery 
is very generally imperfectly studied and. understood. 

As soon as the child is expelled, the uterine fibres contract in all 
directions, and the hand, following the uterus down, will find that it 
forms a firm rounded mass lying in the lower part of the abdominal 
cavity. By retraction of its internal surface the placental attachments, 
which probably remain undisturbed until the expulsion of the child, 
are generally separated, and the after-birth remains in the cavity of 
the uterus as a foreign body. In many, probably in most cases, a 
certain amount of blood is discharged from the utero-placental vessels, 
and is extravasated between the placenta and the uterine walls, these 
coagulating and forming a retro-placental hsematoma, which further 
promotes the separation of the placenta. 

The escape of blood from the open mouths of the uterine sinuses is 
now prevented in two ways, viz.: (1) by the contractions of the uterine 
walls, and the more firm, persistent, and tonic this 
is, the more certain is the immunity from hemor- 
rhage; (2) by the formation of coagula in the 
mouths of the vessels. Any undue haste in pro- 
moting the expulsion of the placenta tends to pre- 
vent the latter of these two haemostatic safeguards, 
and is apt to be followed by loss of blood. After 
a certain time, averaging from a quarter to half 
an hour, the uterus will be felt to harden, and, if 
the case be solely left to nature, what has been 
aptly called a miniature labor occurs. Pains 
come on, and the placenta is spontaneously ex- 
pelled from the uterus, either into the canal of the 
vagina or even externally. In most obstetric works 
it is stated that the after-birth may be separated 
either from its centre or edge, and that it is very 
generally expelled through the os in an inverted 
form, with its fcetal surface downward, and folded 
transversely on itself. That this is the mode in 
which the placenta is often expelled, when traction 
on the cord is practised, is a matter of certainty. 

It then passes through the os very much in the shape of an inverted 
umbrella. It is certain, however, that this is not the natural mechan- 



FlG. 97. 




Mode in which the pla- 
centa is naturally ex- 
pelled. (After Duncan.) 



280 LABOR. 

ism of its delivery. The subject has been well studied by Berry Hart, 1 
who has shown that during the contractions of the third stage of labor 
the placenta is " thrown into heights and hollows," and, if the case be 
left entirely to nature, it descends with its edge or a point near its edge 
first, its uterine and detached surface gliding along the inner surface 
of the uterus, the foldings of its structure being parallel to the long 
diameter of the uterine cavity (Fig. 97). At the same time the mem- 
branes, previously loosed by retraction of the uterine walls, are peeled 
off, and follow the placenta as it is expelled. In this way it is expelled 
into the vagina, and during the process little or no hemorrhage occurs. 
When the placenta is drawn out in the way too generally practised, it 
obstructs the aperture of the os, and, acting like the piston of a pump, 
tends to promote hemorrhage. The corollaries as to treatment drawn 
from these facts will be subsequently considered. I am anxious, how- 
ever, here to direct attention to nature's mechanism, because I believe 
there is no part of labor about the management of which erroneous 
views are more prevalent than that of this stage, and none in which 
they are more apt to lead to serious consequences ; and unless the mode 
in which nature effects the expulsion of the placenta and prevents hem- 
orrhage is thoroughly understood, we shall certainly fail in assisting 
her in a proper manner. In the large proportion of cases, when It ft 
entirely to themselves, the placenta would be retained, if not in the 
uterus, at any rate in the vagina, for a considerable time — possibly for 
several hours; and such delay would very unnecessarily tire the 
patience of the practitioner and be prejudicial to the patient. It is, 
therefore, our duty in the majority of cases to promote the expulsion 
of the after-birth ; and when this is properly and scientifically done, 
we increase rather than diminish the patient's safety and comfort. 
But in order to do this we must assist nature, and not act in opposition 
to her method, as is so often the case. 

After-pains. — When once the placenta is expelled the uterus con- 
tracts still more firmly, and in a typical case is felt just above the 
pelvic brim, hard and firm, and about the size of a cricket-ball. Gen- 
erally for several hours, or even for one or two days, it occasionally 
relaxes and contracts, and these contractions gives rise to the " after- 
pains" from which women often suffer much. The object of these 
pains is no doubt to expel any coagula that may remain in the uterus, 
and, therefore, however unpleasant they may be to the patient, they 
must be considered, unless very excessive, to be salutary rather than 
otherwise. 

Duration of Labor. — The length of labor varies extremely in 
different cases, and it is quite impossible to lay down any definite rules 
with regard to it. Subject to exceptions, labor is longer in primiparse 
than in multipara, on account of the greater resistance of the soft parts 
to the former, especially of the structures about the vagina and vulva. 
It is also generally stated that the difficulty of labor increases with the 
age of the patient, and that in elderly primiparse it is likely to be 
unusually tedious, from rigidity of the soft parts. It is very doubtful 

i Berry Hart : " Sectional Anatomy of Labor." Edin. Med. Journ., November, 18S7. 



THE PHENOMENA OF LABOR. 281 

if this opinion has any real basis, and in such cases the practitioner 
often finds himself agreeably disappointed in the result. Mr. Eoper, 1 
indeed, argues that the wasting of the tissues which occurs after forty 
years of age diminishes their resistance, and that first labors after that 
age are easier, as a rule, than in early life. The habits and mode of 
life of patients have no doubt a considerable influence on the duration 
of labor, but we are not in possession of any very reliable facts with 
regard to this subject. It is reasonable to suppose that the tissues of 
large, muscular, strongly-developed women will offer more resistance 
than those of slighter build. On the other hand, women of the latter 
class, especially in the upper ranks of life, more often develop nervous 
susceptibilities, which may be expected to influence the length of their 
labors. The average duration of labor, calculated from a large number 
of cases, is from eight to ten hours ; even in priniiparse, however, it is 
constantly terminated in one or two hours from its commencement, 
and may be extended to twenty-four hours without any symptoms of 
urgency arising. In multipara? it is frequently over in even a shorter 
time. Indications calling for interference may arise at any time during 
the progress of labor, independently of its length. The proportion 
between the length of the first and second stages also varies consider- 
ably. The first stage is generally the longest, and it is stated by 
Cazeaux to be normally about twice the length of the second. This is 
probably under the mark, and I believe Joulin to be nearer the truth 
in stating that the first stage should be to the second as four or five to 
one, rather than as two to one. Often when the first stage has been 
very prolonged, the second is terminated rapidly. 

the practitioner is constantly asked as to the probable length of 
labor, and the uncertainty of this should always lead him to give a most 
guarded opinion. Even when labor is progressing apparently in the most 
satisfactory manner the pains frequently die aw T ay, and delivery may 
be delayed for many hours. In the first stage a cervix that is appa- 
rently rigid and unyielding may rapidly and unexpectedly dilate, and 
delivery soon follow. In either case, if the practitioner has committed 
himself to a positive opinion he is apt to incur blame, and it is far 
better always to be extremely cautious in our predictions on this point. 

Period of the Day at which Labor Occurs. — A somewhat larger 
proportion of deliveries occur in the early hours of the morning than 
at other times. Thus West 2 found that out of 2019 deliveries, 780 
took place from 11 p.m. to 7 a.m., 662 from 7 a.m. to 3 p.m., and 577 
from 3 p.m. to 11 p.m. 

1 Obst. Trans., vol. vii. p. 51. 2 Amer. Med. Journ., 1854. 



282 LABOR, 



CHAPTEE II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of the Subject. — It is quite impossible to over-esti- 
mate the importance of thoroughly understanding the mechanism of 
the passage of the foetus through the pelvis. This dominates the whole 
scientific practice of midwifery, and the practitioner cannot acquire 
more than a merely empirical knowledge, such as may be possessed 
by any uneducated midwife, or conduct the more difficult cases requir- 
ing operative interference, with safety to the patient or satisfaction to 
himself, unless he thoroughly masters the subject. 

In treating of the physiological phenomena of labor it was assumed 
that we had to do with an ordinary case of head presentation, the 
description being applicable, with slight variations, to presentations of 
other parts of the foetus. So in discussing the mechanical phenomena 
of delivery, I shall describe more in detail the mechanism of head pre- 
sentations, reserving any account of the mechanism of other presenta- 
tions until they are separately studied. Head presentation is so much 
more frequent than that of any other part — amounting to 95 per cent. 
of all cases — that this mode of studying the subject is fully justified ; 
and, when once the student has mastered the phenomena of delivery 
in head presentations, he will have little difficulty in understanding 
the mechanism of labor when other parts of the foetus present, based, 
as it always is, on the same general plan. 

Mode of Recognizing- the Position of the Head by its Sutures 
and Fontanelles. — In entering on this study we come to appreciate 
the importance of the sutures and fontanelles in enabling us to detect 
the position of the foetal head, and to watch its progress through the 
pelvis; and unless the tactus eruditus by which these can be dis- 
tinguished from each other has been acquired, the practitioner will be 
unable to satisfy himself of the exact progress of the labor. Nor is 
this always easy. Indeed, it requires considerable experience and 
practice before it is possible to make out the position of the head with 
absolute certainty ; but this knowledge should always be aimed at, and 
the student will never regret the time and trouble he spends in ac- 
quiring it. 

At the commencement of labor the long diameter of the head lies in 
almost any diameter of the pelvic brim, except in the antero-posterior, 
where there is not space for it. In the large majority of cases, how- 
ever, it enters the pelvis in one or other of the oblique diameters, or 
in one between the oblique and transverse ; but until it has fairly 
passed through the brim, it more frequently lies directly in the trans- 
verse diameter than has been generally supposed. Hence obstetricians 



DELIVERY IN HEAD PRESENTATION'S, 



283 



are in the habit of describing the head as lying in four positions 
according to the parts of the pelvis to which the occipnt points ; the 
first and third positions being those in Avhich the long diameter of the 
head occupies the right oblique diameter of the pelvis, the second and 
fourth those in which it lies in the left oblique. Many subdivisions 
of these positions have been made, which only complicate the subject, 
and render it more difficult to understand. 

Pour Positions Described. — The positions, then, of the foetal head 
after it has entered the brim, which it is of importance to be able to 
distinguish in practice, are : 

First {left occipitoanterior, occipito-lceva anterior, o.l.a.). The occiput 
points to the left foramen ovale, the sinciput to the right sacro-iliac 
synchondrosis, and the louo; diameter of the head lies in the right 
oblique diameter of the pelvis. 

Second (right occipitoanterior, occipito-dextra anterior, o.d.a.). The 
occiput points to the right foramen ovale, the forehead to the left 
sacro-iliac synchondrosis, and the long diameter of the head lies in the 
left oblique diameter of the pelvis. 

Third (right oceipito-posterior, occipito-dextra posterior, o.d.p.). The 
occiput points to the right sacro-iliac synchondrosis, the forehead to the 
left foramen ovale, and the long diameter of the head lies in the right 
oblique diameter of the pelvis. This position is the reverse of the first. 

Fourth (left oceipito-posterior, occipito-lceva posteriory o.l.p.). The 
occiput points to the lefb sacro-iliac synchondrosis, the forehead to the 
right foramen ovale, and the long diameter of the head lies in the left 
oblique diameter of the pelvis. This position is the reverse of the second. 

The relative frequency of these positions has long been, and still is, 
a matter of discussion among obstetricians. According to Xaegele, to 
whose classical essay we owe the greater part of our knowledge of the 
subject, the head lies in the right oblique diameter in 99 per cent, of 
all cases. More recent researches have thrown some doubt on the 
accuracy of these figures, and many modern obstetricians believe that 
the second (o.d.a.) position, which Xaegele believed only to be ob- 
served as a transitional stage in the natural progress of the third 
(o.d.p.) position, is much more common than he supposed. This 
question will be more fully discussed when we treat of the mechanism 
of oceipito-posterior delivery, and, in the meantime, it may serve to 
show the discrepancy which exists in the opinions of modern writers, 
if we append the following table of the relative frequency of the 
various positions, 1 copied from Leishman's work : 



Kaegele 
Naegele, Jr. 
Simpson and Barry 
Dubois . 
Murphy 
Swayne 



First 


Second 


, Thinl 


Fourth 


position 


position 


position 


position 


(O.L.A.) 


(O.D.A.) 


(O.D.P ) 


(O.L.P.) 


70.00 




29.00 




1 1.' \ 




32.88 




76.45 


0.29 




0.58 




2.87 


25.66 


0.62 




16.18 


16 18 


4.42 


86.36 


9.79 


1.04 


2.8 



Not 
classified. 



1.00 
2.47 



1 Leishman's System of Midwifery, p. 341. 



284 LABOR. 

Here it will be seen that all obstetricians are agreed as to the 
immensely greater frequency of the first (o.L.A.) position — the only 
point at issue being the relative frequency of the second (o.d.a.) and 
third (o.d.p.). 

Various explanations have been given of the greater frequency with 
which the head lies in the right oblique diameter. By some it is re- 
ferred to the natural tendency of the back of the foetus, as shown by 
the experimental researches of Honing and other writers, to be directed, 
in consequence of gravitation, forward and to the left side of the 
mother in the erect attitude, and backward and to her right side in 
the recumbent. The explanation given by Simpson was that the head 
lay in the right oblique diameter in consequence of the measurement 
of the left oblique being more or less lessened by the presence of the 
rectum. When the rectum is collapsed, indeed, the narrowing of the 
diameter is slight ; but it is so often distended by fecal matter — some- 
times, when constipation exists, to a very great extent — that it may 
readily have a very important influence in determining the position of 
the foetal head. 

In describing the mechanism of delivery, it will be well for us to 
concentrate our attention on the first (o.L.A.), or most common, posi- 
tion, dwelling subsequently more briefly on the differences between it 
and the less common ones. 

Description of the First Position. — In this position, when the 
head commences to descend, the occiput lies in the brim pointing to 
the left ilio-pectineal eminence, the forehead is directed to the right 
sacro-iliac synchondrosis, and the sagittal runs obliquely across the 
pelvis in the right oblique diameter. The back of the child is turned 
toward the left side of the mother's abdomen, the right shoulder to her 
right side, the left to her left side (Fig. 98). If a vaginal examination 
be now made (the patient lying in the ordinary obstetric position), and 
the os be sufficiently open, the finger will impinge upon the protuber- 
ance of the right parietal bone, which is described as the " presenting 
part," a term which has received various definitions, the best of which 
is probably that adopted by Tyler Smith, viz., "that portion of the 
foetal head felt most prominently within the circle of the os uteri, the 
vagina, and the ostium vaginse, in the successive stages of labor." If 
the tip of the examining finger be passed slightly upward, it will feel 
the sagittal suture running obliquely across the pelvis, and, if this be 
traced downward and to the left, it will come upon the triangular poste- 
rior fontanelle, with the lambdoidal sutures diverging from it. If the 
finger could be passed sufficiently high in the opposite direction, 
upward and to the right, it would come upon the large anterior fonta- 
nelle ; but at this time that is too high up to be within reach. The 
chin is slightly flexed upon the sternum, this flexion, as we shall 
presently see, being greatly increased as the head begins to descend. 

The head, at the commencement of labor, generally lies within the 
pelvic brim, especially in primiparse. In multipara?, owing to the 
relaxation of the abdominal parietes, the uterus is apt to fall somewhat 
forward, and the head consequently is more entirely above the brim, 
but is pushed within it as soon as labor actually commences. 



DELIVERY IN HEAD PRESENTATIONS. 285 

Kaegele — and his description has been adopted by most subsequent 
writers — describes the head, at this period, as lying obliquely in rela- 
tion to the brim, the right parietal bone, on which the examining finger 
impinges, being supposed by him to be much lower than the left. The 
accuracy of this view has, of late years, been contested, and it is now 
pretty generally admitted that this obliquity does not exist, and that 

Fig. 98. 




Attitude of child in first position (o.l.a.). (After Hodge.) 

the head enters the brim of the pelvis with both parietal bones on the 
same level, and with its bi-parietal diameter parallel to the plane of 
the inlet (Fig. 99). Xaegele's view was adopted, partly because the 
finger ahvays felt the right parietal protuberance lowest, and partly 
because it was at that point that the " caput succedaneum" or swelling 
observed on the head after delivery, was always formed. Both argu- 
ments are, however, fallacious ; for the right parietal bone is the part 
which would naturally be felt lowest, on account of the oblique posi- 
tion of the pelvis to the trunk ; while, with regard to the caput suc- 
cedaneum, it has been conclusively proved by Duncan that it does not 
form on the point most exposed to pressure, as Xaegele assumed, but 
on the part of the head where there is least pressure — that is, the part 
lying over the axis of the vaginal canal. 

Division of Mechanical Movements into Stages. — In tracing 
the progress of the head from the position just described, obstetricians 
have been in the habit of dividing the movements it undergoes into 
various stages, which are convenient for the purpose of facilitating 
description. It must be borne in mind that these are not evident and 
distinct stages, which can always be made out in practice, but that 
they run insensibly into one another, and often occur simultaneously, 
or nearly so, in rapid labor. They may be described as : 1. Flexion. 
2. First movement of descent. 3. Levelling or adjusting movement. 



286 -LABOR. 

4. Rotation. 5. Second movement of descent and extension. 6. External 
rotation. 

1. Flexion. The first movement of the head consists of a rotation 
on its bi-parietal diameter, by which the chin of the child becomes 
bent on the sternum, and the occiput descends lower than the forehead. 
By this there is a clear gain of at least a half-inch, for the occipito- 
bregmatic diameter (3J inches) becomes substituted for the occipito- 
frontal (4J inches). (Fig. 99). 

Fig. 99. 




First position (o.l.a.) : Movement of flexion. 

The movement is most marked when the pelvis is narrow, and in 
some cases of pelvic deformity it takes place to an extreme degree ; 
while, in unusually large and roomy pelves, it occurs to a very slight 
extent, or not at all. The reason of this flexion is twofold. Solayres 
and the majority of obstetricians explain it by saying that the expul- 
sive force is communicated to the head through the vertebral column, 
and inasmuch as the head is articulated much nearer the occiput than 
the sinciput, the resistance being equal, the former must be pushed 
down. This is, doubtless, the correct explanation of the flexion after 
the membranes are ruptured ; but, before that happens, the ovum is 
practically a bag of water, which is equally compressed at all points 
by the uterine contraction, and is pushed downward through the os 
en masse, the expulsive force not being transmitted through the ver- 
tebral column at all. Under such circumstances flexion is probably 
effected in the following way : the head being articulated nearer the 
occiput than the forehead, and being equally pressed upon from below 
by the resisting structures, the pressure is more effectual on the fore- 
head — consequently that is forced upward, and the occiput descends. 
This explanation would also hold good after the rupture of the mem- 
branes, and probably both causes assist in effecting the movement. 

2 and 3. Descent and levelling movement. The movements of descent 
and levelling may be described together. As soon as the head is liber- 



DELIVERY IN HEAD PRESENTATIONS. 287 

ated from the os uteri, it descends pretty rapidly through the pelvis, 
until the occiput reaches a point nearly opposite the lower part of the 
foramen ovale (Fig. 100), and the sinciput is opposite the second bone 
of the sacrum. A levelling movement now occurs, the anterior fonta- 
nelle comes to be more easily within reach, more on a level with the 
posterior, and the chin is no longer so much flexed on the sternum. 
This change is due to the fact that the anterior end of the ovoid 
experiences greater resistance than the posterior, and as soon as this 
resistance counterbalances and exceeds that applied to the latter, the 
sinciput must descend. The right side of the head also descends more 
than the left from a similar cause, so that the head becomes, as it were, 
slightly flexed on the right shoulder. This obliquity of the head on 
its transverse diameter in the lower part of the pelvis has been denied 

Fig. 100. 




First position (o. l. a.) : Occiput in the cavity of the pelvis. (After Hodge.] 



by Kiineke, 1 who maintains that the head passes through the entire 
pelvis in the same position as it enters the brim ; that is, with both 
parietal bones on a level, so that the point of intersection of the trans- 
verse and antero-posterior diameters of the pelvis would correspond 
with the sagittal suture. There is, however, good reason to believe 
that in the lower half of the pelvic cavity the head is not truly 
synclitic, as Kiineke describes, but that the right parietal bone is on 
a somewhat lower level than the left. 

4. Rotation. The movement of rotation is very important. By it 
the long diameter of the head is changed from the oblique diameter 
of the pelvic cavity to the antero-posterior diameter of the outlet 
(Fig. 101), or to a diameter nearly corresponding to it, so that the 
long diameter of the head is brought into relation with the longest 
diameter of the pelvic outlet. This alteration almost always takes 
place, and may be readily observed by the accoucheur who carefully 
watches the progress of labor. Various explanations have been given 
of its causes. The one most generally adopted is, that it is due to the 
projection inward of the ischial spines, which narrow the transverse 
diameter of the pelvic outlet. As the pains force the occiput down- 
ward, its rotation backward is prevented by the projection of the left 
ischial spine, while its rotation forward is favored by the smooth 
bevelled surface of the ascending ramus of the ischium. Similarly 

i t)ie vier Factoren der (ieburt. Berlin, 1869. 



288 LABOR. 

the ischial spine on the opposite side prevents the rotation forward ol 
the forehead, which is guided backward to the cavity of the sacrum 
by the smooth surface of the sacro-ischiatic ligaments. These arrange- 
ments, therefore, give a screw-like form to the interior of the pelvis ; 
and as the pains force the head downward they are effectual in im- 
parting to it the rotatory movement which is of such importance in 
adapting it to the longest measurement of the outlet. 

By most of the German obstetricians the influence of the ischial 
spines aud of the smooth pelvic planes in producing rotation is not 
admitted. They rather refer the change of direction to the increased 
resistance the head meets from the posterior wall of the pelvis, and 
from the perineal structures. Whichever part of the head first meets 
this resistance, which is much greater than that of the anterior part of 
the pelvis, must necessarily be pressed forward ; and as, in the large 

Fig. 101. 




First position (o.l.a.) : Occiput at outlet of the pelvis. (After Hodge.) 

majority of cases, the posterior fontanelle descends first, it is thus 
pressed forward until rotation is effected. The fact that while rotation 
almost always occurs in primiparse, it often fails in multipara, in 
whom the perineum is frequently deficient, favors this explanation. 
This view has the advantage of accounting equally well for the rotation 
in occipito-posterior as in occipi to-anterior positions, the former of 
which, on the more ordinarily received theory, are not quite satisfac- 
torily explicable. It does not follow that the smooth surfaces of the 
pelvic planes are without influence in favoring the rotation. On the 
contrary, they doubtless greatly facilitate it ; and it is probable that 
both these agencies operate in producing anterior rotation of the 
occiput. 

In some rare cases the head escapes rotation and reaches the perineum 
still lying in the oblique diameter. Even here, however, rotation is 
generally effected, often suddenly, just as the head is about to pass the 
vulva, and it is very rarely expelled in the oblique position. The 
movement at this stage may be explained by the perineum, which is 
attached at its sides, and grooved in its centre ; to the hollow so formed 
the long diameter of the head accommodates itself, and is thus rotated 
into the antero-posterior diameter of the outlet. 

5. Extension. By the process just described the face is turned back 
into the hollow of the sacrum ; but the head does not lie absolutely in 
the antero-posterior diameter of the pelvic outlet, but rather in one 
between it and the oblique. The occiput is still forced down by the 



DELIVERY IN HEAD PRESENTATIONS. 



289 



pains, and, in consequence of its altered position, is enabled to pass 
between the rami of the pubis, and advances until its further descent 
is checked by the nape of the neck, which is pressed under and against 
the arch of the pubes (Fig. 102). By this means the occiput is fixed, and, 
the pains continuing, the uterine force no longer acts on the occiput, 
but on the anterior part of the head, which is now pushed down and 

Fig. 102. 




First position (o.l.a.) : neck fixed under the arch of the pubes, extension commencing. 
(After Farabeuf.) 



Fig. 10<5. 




• First position (o.l.a.) : head delivered. (After Hodge.) 

separated from the sternum. This constitutes extension. As the head 
descends, the soft structures of the perineum are stretched, and the 
coccyx pushed back so as to enlarge the outlet. The pains continue to 
distend the perineum more and more, the head advancing and receding 

19 



290 LABOR. 

with each pain. As the forehead descends, the sub-occipito-bregmatic, 
the sub-occipito-fmntal, and the sub-occipito- mental diameters succes- 
sively present ; the occiput turns more and more upward in front of 
the pubes (Fig. 103), and, at last, the face sweeps over the perineum 
and is born. 

The mechanical cause of this movement may be readily explained. 
As soon as the occiput has passed under the arch of the pubes, and is 
no longer resisted by the anterior pelvic walls, the head is subjected to 
the action of two forces : that of the uterine pressure acting downward 
and backward ; and that of the resistance of the posterior walls of the 
pelvis and the soft parts acting almost directly forward. The necessary 
result is that the head is pushed in a direction intermediate between 
these two opposing forces — that is, downward and forward in the axis 
of the pelvic outlet. 

In addition to the slight obliquity which exists as regards the direct 
relation of the long diameter of the head to the antero-posterior 
diameter of the outlet at the moment of its expulsion, the head also lies 
somewhat obliquely in relation to its own transverse diameter, so that, in 
the majority of cases, the right parietal bone is expelled before the left. 

6. External rotation. Shortly after the head is expelled, as soon as 
renewed uterine action commences, it may be observed to make a 
distinct rotatory movement, the occiput turning to the left thigh of the 

Fig. 104. 



External rotation of head in first position (o.l.a.). (After Hodge.) 

mother, and the face turning upward to the right thigh (Fig. 104). 
The reason of this is evident. When the head descends in the right 
oblique diameter the shoulders lie in the opposite or left oblique 
diameter, and, as the head rotates into the antero-posterior diameter, 
they are necessarily placed more nearly in the transverse. As soon as 
the head is expelled the shoulders are subjected to the same uterine 
force and pelvic resistance as the head has just been, and they are acted 
on in precisely the same way. Consequently they too rotate, but in 
the opposite direction, into the antero-posterior diameter of the outlet, 
or nearly so, just as the head did, and as they do so they necessarily 
carry the head with them, and cause its external rotation. 



DELIVERY IN HEAD PRESENTATIONS. 



291 



The two shoulders are soon expelled, the left shoulder generally the 
first, sweeping ovei the perineum in the same manner as the face. 
This is, however, not always the ease, and they are often expelled 
simultaneously, or the right shoulder may come first. The body soon 
follows, and the second stage of labor is completed. 

Second Position. — In the secoud position (o.d.a.) the long diameter 
of the head lies in the left oblique diameter of the pelvis (Fig. 105). 
On making a vaginal examination, in the ordinary obstetric position, 
the finger, passing upward and to the right, feels the small posterior 
fontanelle : downward and to the left, it feels the anterior. The sag- 

FlG, 105. 




Attitude of the child in the second position (o.d.a.). (After Fakabeuf.) 

gital suture lies obliquely across the pelvis in the left oblique diameter. 
The description of the mechanism of delivery is precisely the same as 
in the first position (o.l.a.), substituting the word left for right. Thus 
the finger impinges on the left parietal bone, the occiput turns from 
right to left during rotation. After the birth of the head the occiput 
turns to the right thigh of the mother, the face to the left thigh. 

Third, or Right Occipito-sacro-iliac Position. — In the third posi- 
tion (o.d.p.) the head enters the pelvic brim with the occiput directed 
backward to the right sacro-iliac synchondrosis, and the sinciput for- 
ward to the left foramen ovale (Fig. 106). The posterior fontanelle is 
directed backward, the anterior fontanelle forward, while the examin- 
ing finger impinges on the left parietal bone. The mechanism of 
delivery in these cases is of much interest. In the large majority of 
cases, during the progress of delivery the occiput rotates forward along 
the right side of the pelvis, until it comes to lie almost in the antero- 
posterior diameter of the outlet, and passes under the pubic arch, the 
forehead passing over the perineum. It will be seen that during part 



292 



LABOR, 



of this extensive rotation the head must lie in the second position 
(o.d.a.), and the case terminates just as if it had been in the second 
position (o.d.a.) from the commencement of labor. 

Manner in which the Occiput is Rotated Forward. — How is it 
that this rotation is effected, and that the sinciput, occupying the posi- 
tion of the occiput in the first position (o.l.a.), should not be rotated 
forward to the pubes as that is ? This, no doubt, may be explained by 
the fact that the uterine force transmitted through the vertebral column 



Fig. 106 




Attitude of the child in the third position (o.d.p.). (After Farabeuf.) 

causes the occiput to descend lower than the sinciput, so that in most 
cases, in making a vaginal examination, the posterior fontanelle can be 
readily felt, while the anterior is high up and out of reach. The head 
is, therefore, extremely flexed, and so descends into the pelvic cavity, 
until the occiput, being now below the right ischial spine, experiences 
the resistance of the pelvic floor, opposite the right sacro-ischiatic liga- 
ment, by which it is directed forward. The forehead is, at this time, 
supposing flexion to be marked, too high to be influenced by the 
anterior pelvic plane. Pressure continuing, the occiput rotates for- 
ward, the forehead passes around the left side of the pelvis, and labor 
is terminated as in the second position (o.d.a.). 

The period of labor at which rotation takes place varies. In the 
majority of cases it does not occur until the head is on the floor of the 
pelvis, for it is then that resistance is most felt ; but the greater the 
resistance, the sooner will rotation be produced. Hence it is more 
likely to occur early, when the head is large and the pelvis compara- 
tively small. 

The facility with which this movement is effected obviously depends 



DELIVERY IN HEAD PRESENTATIONS. 293 

upon the complete flexion of the chin on the sternum, by which the 
anterior fontanelle is so elevated that its rotation backward is not resisted 
by the inward projection of the left ischial spine, and the occiput is 
correspondingly depressed. If, however, this flexion is not complete, 
and the anterior fontauelle is so low as to be readily within reach of 
the linger, considerable difficulty is likely to be experienced. In many 
such cases rotation is still eventually effected, but in others it is not; and 
the labor is then terminated with the face to the pubes, but at the ex- 
pense of considerable delay and difficulty. According to Dr. Uvedale 
West, of Alford, who devoted much careful study to the subject, this 
termination occurs in about 4 per cent, of occipito-posterior positions, 
AVhen it is about to happen the anterior fontanelle may be felt very 
low down, and sometimes even the forehead and superciliary ridges. 
The uterine force pushes down the occiput, the sinciput being fixed 
behind the pubes, which it obviously cannot pass under, as does the 
occiput in the first position. The sinciput, therefore, becomes more 
flexed and pushed upward, while the resistance of the pelvic floor 
directs the occiput forward. The perineum now becomes enormously 
distended by the back part of the head, and is in great danger of 
laceration. The occiput is eventually, but not without much difficulty, 
expelled. A process of extension now occurs, the nape of the neck 
being fixed, as it were, against the centre of the perineum, the expel- 
ling force now acting on the forehead, and producing rotation of the 
head on its transverse axis. The forehead and face are thus protruded, 
and the body follows without difficulty. 

It is said that, in a few exceptional cases, where the anterior fontanelle 
is much depressed, the labor may terminate by the conversion of the 
presentation into one of the face, the head rotating on its transverse 
axis, the forehead passing to the posterior part of the pelvis, and the 
chin emerging under the pubes. It is obvious, however, that this 
change can only occur when the head is unusually small, and it must 
of necessity be extremely rare. 

Reference has already been made to Xaegele's views as to the rarity 
of the second position (o.d.a.), and to his opinion that cases in which 
the occiput was found to point to the right foramen ovale were only 
transitional stages in the rotation of occipito-posterior positions. Such 
an assumption, however, is unwarrantable, unless the case has been 
watched from the very commencement of labor. Many perfectlv 
qualified observers have arrived at the conclusion that second posi- 
tions (o.d.a.) are far more common than Xaegele supposed ; and in 
the table already quoted (page 283) it will be seen that while Murphy 
estimates the second (o.d.a.) and third (o.d.p.) as being equally fre- 
quent, Swayne believes the second (o.d.a.) to be much more common 
than the third (o.d.p.). It is probable that the weight of Naegele's 
authority has induced many observers to classify second (o.d.a.) posi- 
tions as third (o.d.p.) positions in which partial rotation has already 
been accomplished. My own experience would certainly lead me to 
think that second (o.d.a.) positions are very far from uncommon. The 
question, however, must be considered to be in abeyance, until further 
observations by competent authorities enable us to decide it conclu- 
sively. 



294 LABOR, 

Fourth, or Left Occipito-sacro-iliac Position. — The fourth posi- 
tion (o.l.p.) is just as much the reverse of the second as the third is of 
the first. The occiput points to the left (Fig. 107) sacro-iliac syn- 
chondrosis, and the finger impinges on the right parietal bone. The 
mechanism is precisely the same as in the third position (o.d.p.), the 
rotation taking place from left to right. 




Fourth position (o.l.p.) of occiput at pelvic brim. 

Formation of the Caput Succedaneum. — The formation of the 
caput succedaneum has been already alluded to. This term is applied 
to the oedematous swelling which forms on the head, and is produced 
by effusion from the obstruction of the venous circulation caused by 
the pressure to which the head is subjected. It follows that the size 
of the swelling is in direct proportion to the length of the labor. In 
rapid deliveries, in which the head is forced through the pelvis quickly, 
it is scarcely, if at all, developed ; while after protracted labor it is 
large and distinct, and may obscure the diagnosis of the position, by 
preventing the sutures and fontanelles being felt. Its situation varies 
according to the position of the head : thus, in the first (o.l.a.) and 
fourth (o.l.p.) positions it forms on the right parietal bone, in the 
second (o.d.a.) and third (o.d.p.) on the left ; and we may therefore 
verify, by inspection of its site, the accuracy of our diagnosis. 

An ordinary mistake w r hich has been made by obstetricians is to 
regard the caput succedaneum as formed at the point where the head 
has been most subjected to pressure ; while, in fact, it forms on that 
part which is most unsupported by the maternal structures, and where 
the swelling may consequently most readily occur. Therefore, in the 
early stages of the labor, it always forms on the part of the head which 
lies in the circle of the os uteri ; while in subsequent stages, it forms 
on that which lies in the axis of the vaginal canal, and eventually is 
most prominent on the part that is first expelled from the vulva. 

Alteration in the Shape of the Head from Moulding. — A few 
words may be said as to the alteration in the form of the foetal head 
which occurs in tedious labors, and results from the moulding which 
it has undergone in its passage through the pelvis. The smaller the 
pelvis, and the greater the pressure applied to the head during delivery, 



MANAGEMENT OF NATURAL LABOR. 295 

the more marked this is. The result is, that in vertex presentations 
the occipito-mental and oecipito-frontal diameters are elongated to the 
extent of an inch, or even more, while the transverse diameters are 
lessoned, from compression of the parietal bones. This moulding is 
of unquestionable value in facilitating the birth of the child. The 
amount of apparent deformity is very considerable, and may even give 
rise to some anxiety. It is well to remember, therefore, that it is 
always transient, and that in a few hours, or days at most, the elas- 
ticity of the soft cranial bones causes them to resume their natural 
form. The caput succedaneum also disappears rapidly ; therefore no 
amount of deformity from either of these causes need give rise to 
anxiety, or call for any treatment. 



CHAPTEE III. 

MANAGEMENT OF NATURAL LABOR. 

Although labor is a strictly physiological function, and in a large 
majority of cases might, no doubt, be safely accomplished without 
assistance from the accoucheur, still medical aid, properly given, is 
always of value in facilitatiug the process, and is often absolutely 
essential for the safety of the mother and child. 

Preparatory Treatment. — The management of the pregnant woman 
before delivery is a point which should always receive the attention of 
the medical attendant, since it is of consequence that the labor should 
come on when she is in as good a state of health as possible. For this 
purpose ordinary hygienic precautions should never be neglected in 
the latter months of gestation. The patient should take regular and 
gentle exercise, short of fatigue, and if the weather permit, should 
spend as much of her time as possible in the open air. Hot rooms, 
late hours, and excitement of all kinds should be strictly avoided. 
The diet should be simple, nutritious, and unstimulating. The state 
of the bowels should be particularly attended to. During the few 
days preceding labor the descent of the uterus often causes pressure on 
the rectum, and prevents its evacuation. Hence it is customary to 
prescribe occasional gentle aperients, such as small doses of castor oil, 
for a few days before the expected period of delivery. Some caution, 
however, is necessary, as it is certainly not very uncommon for labor to 
be determined rather soouer than was anticipated, in consequence of 
the irritation of too large a purgative dose. The state of the bowels 
should always be inquired into at the commencement of labor, and, if 
there be any reason to suspect that they are loaded, a copious enema 
should be administered. This is always a proper precaution to take, 
for a loaded rectum is a common cause of irregular and ineffective 
uterine action ; and even when it does not produce this result, the escape 



296 LABOR. 

of the feces, in consequence of pressure on the bowel during the propul- 
sive stage, is always disagreeable both to patient and practitioner. 

The dress of the patient during pregnancy may be here adverted 
to; for much discomfort may arise, and the satisfactory progress of 
labor may even be interfered with, from errors in this respect. 

After the uterus has risen out of the pelvis the ordinary corset which 
most women wear is apt to produce very injurious pressure; still more 
so when attempts are made to conceal the increased size by tight lacing. 
After the fourth or fifth month, therefore, the comfort of the patient 
is much increased by wearing a specially constructed pair of stays with 
elastic let into the sides and front, so that they accommodate them- 
selves to the gradual increase of the figure. Such are made by all 
stay-makers, and should be worn whenever the circumstances of the 
patient permit. Failing this, it is better to avoid the use of the corset 
altogether, and to have as little pressure on the uterus as possible ; 
although many women cannot do without the support to which they 
are accustomed. To multipara, especially if there be much laxity of 
the abdominal parietes, a well-fitting elastic abdominal belt is often a 
great comfort. This is constructed so that it can be tightened when 
the patient is walking and in the erect position, when such support 
is most required, and readily loosened when desired. 

Necessity of Attending" to the First Summons. — It is hardly 
necessary to insist on the necessity of the practitioner attending imme- 
diately to the first summons to the patient. It is true that he may 
very often be sent for long before he is actually required. But, on the 
other hand, it is quite impossible to foresee what may be the state of 
any individual case. By prompt attention he may be able to rectify a 
malposition, or prevent some impending catastrophe, and thus save his 
patient from consequences of the utmost gravity. 

The practitioner should always be provided with the articles which 
he may require. The ordinary obstetric cases, containing one or two 
bottles and a catheter, such as are sold by most instrument-makers, are 
cumbrous and useless; while " obstetric bags" are expensive luxuries 
not within the reach of all. Everyone can manufacture an excellent 
obstetric bag for himself, at a small expense, by having compartments 
for holding bottles stitched on to the sides of an ordinary leather bag, 
such as is sold for a few shillings at any portmanteau-maker's. It is 
a great comfort to have at hand all that may be required, and the bag 
should contain chloroform or other anaesthetic, antiseptics in a con- 
centrated form, 1 chloral, laudanum, the liquor ferri perchloridi of the 
Pharmacopoeia, the liquid extract of ergot, and a hypodermatic syringe, 
with bottles containing carbolized oil, ether, and a solution of ergotine 
for subcutaneous injection. If it also contain a Higginson's syringe, 
a small elastic catheter, a good pair of forceps, and one or two suture 
needles, with some silver wire or chromic gut, the practitioner is pro- 
vided against any ordinary contingency. Other articles that may be 

l Dr. Cullingworth recommends a very handy form in which these can be carried. He has a 
box of powders prepared, each of which contains 10 grains of corrosive sublimate, 50 of tartaric 
acid, and 1 of cochineal. One of these, dissolved in a pint of water, makes a 1 : 1000 solution of 
the perchloride of mercury.— Brit. Med. Journ., October 6, 1888. Tabloids of the same strength, 
soluble in water, are now sold by all chemists. 



MANAGEMENT OF NATURAL LABOR. 297 

required, such as thread, scissors, aud the like, are generally provided 
by the nurse or patient. 

Duties on First Visiting* the Patient. — On arriving at the house 
the practitioner should have his visit announced to the patient, and he 
will very often find that the first effect of his presence is to arrest the 
pains that have been hitherto progressing rapidly ; thereby affording a 
very conclusive proof of the influence of mental impressions on the 
progress of labor. If the pains be not already propulsive, it is well 
that he should occupy himself at first in general inquiries from the 
attendants as to the progress of the labor, and in seeing that all the 
necessary arrangements are satisfactorily carried out, so as to allow the 
patient time to get accustomed to his presence. If he have any choice 
in the matter, he should endeavor to secure a large, airy, and well- 
ventilated apartment for the lying-in room, as far removed as possible 
from without. He may also see to the bed, which should be without 
curtains, and prepared for the labor by having a waterproof sheeting 
laid under a folded blanket or. sheet, on which the patient lies. These 
receive the discharges during labor, and can be pulled from under the 
patient after delivery, so as to leave the dry clothes beneath. Among 
the lower classes, the lying-in chamber is considered a legitimate meet- 
ing-place for numerous female friends to gossip, whose conversation is 
often distressing, and is certainly injurious, to a woman in the excitable 
condition associated with labor. The medical attendant should, there- 
fore, insist on as much quiet as possible, and should allow no one in the 
room except the nurse and some one friend whose presence the patient 
may desire. The husband's presence must be left to the wishes of the 
patient. Some women like their husbands to be with them, while 
others prefer to be without them, and the medical attendant is bound 
to act in accordance with the patient's desire. 

Antiseptic Precautions. — Here it is necessary to describe the anti- 
septic precautions which should be adopted in the practice of modern 
midwifery. The marvellous results which have followed the intro- 
duction of antiseptic midwifery into lying-in hospitals in all parts of 
the world, and which have converted these institutions from hotbeds 
of disease into safer places for delivery than the most luxurious homes, 
form one of the most striking chapters in the history of modern medi- 
cine. These will call for more detailed notice when we come to treat 
of puerperal septicaemia. Here it will suffice to state that by universal 
consent it is now recognized as essential that similar care should be 
taken in private practice, and the more scrupulous the practitioner is, 
the less will be the mortality and morbidity he has to deal with among 
his patients. Every practitioner who is old enough to have practised 
before antiseptics were used, and who has rigorously employed them 
of late vears, will gratefully recognize the comparative comfort of his 
present work. The relief from the haunting dread of septic infection, 
which was one of the bugbears of practice in days gone by, is of itself 
an unspeakable boon. It cannot, therefore, be too strongly insisted 
on that minute care in this respect should be taken, both as regards 
the practitioner and the nurse, on whom the subsequent care of the 
patient devolves. 



298 LABOR. 

Strict asepsis in midwifery is, of course, impossible ; but absolute 
cleanliness in connection with labor, along with the free use of suitable 
disinfectants, will reduce to a minimum the risk of infection by germs 
from without. The first thing to be done before making a vaginal 
examination is thoroughly to scrub the hands with soap and water, 
and the nails with a hard brush. This should be insisted on as regards 
the nurse also, a point which is often not sufficiently attended to. A 
basin containing a 1 : 1000 solution of perchloride of mercury should 
be placed by the side of the bed, and the hands should be thoroughly 
washed in the fluid before making a vaginal examination. This ablu- 
tion should be repeated frequently during the course of the labor. It 
has been conclusively shown that no other antiseptic is so reliable, 1 and 
no other should be used for the hands. Instead of using ordinary lard 
or cold cream for lubricating the examining finger, the practitioner 
should carry in his bag for this purpose some disinfecting unguent, 
such as carbolized or eucalyptus vaseline. As soon as labor is estab- 
lished the vulva should be thoroughly washed with soap and water, 
and then wetted with a 1 : 1000 solution, and for this purpose cotton- 
wool soaked in the solution should be used. Sponges, so generally em- 
ployed in labor, should be banished from the lying-in room, since it is 
practically impossible to keep them perfectly clean. 

The use of antiseptic injections before, during, and after labor is 
a point on which there is a considerable divergence of opinion. Many 
object to them altogether as necessitating unnecessary manipulations, 
which may tend to the introduction of infective germs rather than to 
their destruction. Frequent douching during labor is certainly alto- 
gether needless, and has the drawback of washing away the lubricating 
mucous secretion of the vagina. I am myself in the habit of ordering 
a single vaginal injection of 1 : 1000 at the commencement of labor^ 
and no more, and to this there can be no reasonable objection. The 
use of an occasional warm irrigation after labor has always seemed to 
me to increase the comfort of the patient ; but this rather comes to be 
considered under the head of puerperal convalescence. 

Attention to Cleanliness. — The most scrupulous care as to the 
cleanliness of the lying-in room and its furniture is an important 
point to consider. The sheets and linen should be clean and fre- 
quently changed, and sanitary towels should be used to receive the 
discharges instead of napkins, which are apt to be imperfectly cleansed. 
These are points which chiefly concern the nurse, but which it is the 
duty of the practitioner to supervise. It is most important that the 
nurse should have thoroughly impressed on her the necessity of the 
antiseptic precautions we are discussing, since she is in contact with 
the genitals of the patient many times daily, and for many days in 
succession, while the duties of the medical attendant in this respect 
are generally at an end when the labor is over. 

Vaginal Examination. — If pains be actually present a vaginal ex- 
amination is essential, and should not be delayed. It enables us to 
ascertain whether the labor has commenced or not, and whether the 

1 See Boxall on " Fever in Childbed," Obst. Trans., vol. xxxii. p. 224. 



MANAGEMENT OF NATURAL LABOR. 299 

presentation is natural or otherwise. The pains, although apparently 
severe, may be altogether spurious, and labor may not have actually 
commenced. It is of much importance, both for our own credit and 
comfort, that we should be able to diagnose the true character of the 
pains ; for if they be so-called " false " pains, we might wait hours in 
fruitless expectation of progress, while delivery is still far off. The 
necessity of ascertaining, therefore, the actual state of affairs need not 
further be insisted on. 

False pains are chiefly characterized by their irregularity, some- 
times coming on at short intervals, sometimes with many hours between 
them ; they also vary much in intensity, some being very sharp and 
painful, while others are slight and transient. In these respects they 
differ from the true pains of the first stage, which are at first slight 
and short, and gradually recur with increased force and regularity. 
The situation of the two kinds of pains also varies ; the false pains 
being chiefly situated in front, while the true pains are felt most in 
the back, and gradually shoot around toward the abdomen. Nothing 
short of a vaginal examination will enable us to clear up the diagnosis 
satisfactorily. If the labor have actually commenced, the os will be 
more or less dilated, and its edges thinned ; while with each pain the 
cervix will become rigid, and the membranes tense and prominent. 
The false pains, on the contrary, have no effect on the cervix, which 
remains flaccid and undilated ; or, if the os be sufficiently open to 
admit the tip of the finger, the membranes will not become prominent 
during the contraction. Under such circumstances we may confidently 
assure the patient that the pains are false, and measures should be 
taken to remove the irritation which produces them. In the large 
majority of cases the cause of the spurious pains will be found to be 
some disordered state of the intestinal tract ; and they will be best 
remedied by a gentle aperient — such as castor oil, or the compound 
eolocynth pill with hyoscyamus — followed by, or combined with, a 
sedative, such as twenty minims of laudanum or chlorodyne. Shortly 
after this has been administered the false pains will die away, and not 
recur until true labor commences. 

Mode of Conducting- a Vaginal Examination. — For a vaginal 
examination the patient is placed by the nurse on her left side, close 
to the edge of the bed, with the legs flexed on the abdomen. The 
practitioner being seated by the edge of the bed, passes the index 
finger of the right hand, the proper antiseptic precautious having 
previously been taken, up to the vulva, and gently insinuates it into 
the orifice of the vagina, then pushes it backward in the axis of the 
vaginal outlet, and finally turns it upward and forward so as to more 
readily reach the cervix (Fig. 108). This it may not always be easy 
to do, for at the commencement of labor the cervix may be so high as 
to be reached with difficulty, or it may be directed backward so as to 
point toward the cavity of the sacrum. The exploration is often 
much facilitated by depressing the uterus from without, by the left 
hand placed on the abdomen. Our object is not only to ascertain 
the state of the cervix as to softness and dilatation, but also the 
presentation, the condition of the vagina, and the capacity of the 



300 LABOR. 

pelvis. The examination is generally commenced during a pain, at 
which time it is less depressing to the patient ; but in order to be 
satisfactory the finger must remain in the vagina until the pain is 
over, the examination being concluded in the interval between this 
pain and the next. 

In head presentations the round mass of the cranium is generally at 
once felt through the lower part of the uterus, and then we have the 
satisfaction of being able to assure the patient that all is right. Should 
we find it difficult to satisfy ourselves on this point per vaginam, abdo- 
minal palpation (see p. 230) may often give us much valuable infor- 
mation. If the os be sufficiently dilated, we can also feel through it 
the occiput covered by the membranes. It is impossible at this time 
to make out the exact position of the head by means of the sutures and 
fontanelles, which are too high up to be within reach. Nor should any 
attempt be made to do so, for fear of prematurely rupturing the mem- 
branes. The fact that the head is presenting is all that we require to 
know at this stage of the labor. 

Fig. 103. 




Examination during the first stage. 

The condition of the os itself, as to rigidity and dilatation, will 
materially assist us in forming an opinion as to the progress and prob- 
able duration of the labor ; but, although the friends will certainly 
press for an opinion on this point, the cautious practitioner will be care- 
ful not to commit himself to a positive statement, which may so easily 
be falsified. It will suffice to assure the friends that everything is 
satisfactory, but that it is impossible to say with any certainty how 
rapidly, or the reverse, the case may progress. 

If the r>ains be not very frequent or strong, and the os not dilated 



MANAGEMENT OF NATURAL LABOR, 301 

to more than the size of a shilling, a considerable delay rnav be 
anticipated, and the presence of the medical attendant is useless. He 
may, therefore, safely leave the patient for an hour or more, provided 
he be within easy reach. It is needless to say that this should never 
be done unless the exact presentation be made out. If some part other 
than the head be presenting, it will probably be impossible to make it 
out until dilatation has progressed further j and the practitioner must 
be incessantly on the watch until the nature of the case be made out, 
so as to be able to seize the most favorable moment for interference, 
should that be necessary. 

Position of Patient during' First Stage. — The j^osition of the 
patient in the first stage is a matter of some moment. It is a decided 
advantage that she should not be then in a recumbent position on her 
side, as is usual in the second stage ; for it is of importance that the 
expulsive force should act in such a way as to favor the descent of the 
head into the pelvis, i. c, perpendicularly to the plane of its brim, and 
also that the weight of the child should operate iu the same way. 
Therefore, the ordinary custom of allowing the patient to walk about, 
or to recline in a chair, is decidedly advantageous ; and it will often 
be observed that the pains are more lingering and ineffective if she lie 
in bed. If the patient be a multipara, or if the abdomen be somewhat 
pendulous, au abdominal bandage, by supporting the uterus, will 
greatly favor the progress of this stage. Keeping the patient out of 
bed has the further advantage of preventing her being unduly anxious 
for the termination of the labor ; and a little cheerful conversation 
will keep up her spirits, and obviate the mental depression which is 
so common. Good beef-tea may be freely administered, with a little 
brandy-and -water occasionally if the patient be weak, and will be 
useful in supporting her strength. 

Over-frequent vaginal examinations should be avoided, for they 
serve no useful purpose, and are not only apt to irritate the cervix, 
but the more frequent the examination the greater the risk of intro- 
ducing septic matter. They should therefore be minimized as much 
as possible, and only practised when it is deemed necessary to ascer- 
tain the progress of dilatation, and then safeguarded, it is needless to 
say, by the careful antiseptic precautions elsewhere recommended. 

When once the os is fully dilated the membranes may be artificially 
ruptured if they have not broken spontaneously, for they no longer 
serve any useful purpose, and only retard the advent of the propulsive 
stage. This can be easily done by pressing on them, when they are 
rendered tense during a pain, by some pointed instrument, such as the 
end of a hairpin, which is always at hand. In some cases, indeed, it 
is even expedient to rupture the membranes before the os is fully 
dilated. Thus it not unfrequently happens, when the amount of 
liquor amnii is at all excessive, that the os dilates to the size of a 
five-shilling-piece or more ; but, although it is perfectly soft and 
flaccid, it opens up no further until the liquor amnii is evacuated, 
when the propulsive pains rapidly complete its dilatation. Some 
experience and judgment are required in the detection of such cases, 
for if we evacuate the liquor amnii prematurely the pressure of the 



302 LABOR. 

head on the cervix may produce irritation, and seriously prolong the 
labor. This manoeuvre is most likely to be useful when the pains are 
strong and the os perfectly flaccid, but when the membranes do not 
protrude through the os so as to eifect further dilatation. 

It is sometimes not easy to ascertain whether the membranes are 
ruptured or not. This is most likely to be the case when the head is 
low down, and the amount of liquor amnii is so small that the pouch 
does not become prominent during the pains. A little care, however, 
will enable us, if the membranes be ruptured, to feel the rugosities of 
the scalp covered with hair, and to distinguish it from the smooth 
polished surface of the membranes. 

After the evacuation of the liquor amnii there is generally a lull in 
the progress of the labor, the pains, however, soon recurring with 
increased force and frequency, and propelling the head through the 
pelvic cavity. The change in the character of the pains is soon appre- 
ciated by the bearing-down efforts by which they are accompanied, as 
well as by their increased length and intensity. 

Position of the Patient during the Second Stage. — It is now 
advisable that the patient be placed in bed ; and in England it is 
usual for her to lie on her left side, with her nates parallel to the edge 
of the bed, and her body lying across it. This is the established 
obstetric position in our country, and it would be useless to attempt to 
insist on any other, even if it were advisable. Although the dorsal 
position is preferred on the Continent, it is difficult to see wherein its 
advantages consist. It certainly leads to unnecessary exposure of the 
person, and it is, on the whole, less easy to reach the patient, so placed, 
for the necessary manipulations. Moreover, the dorsal position in- 
creases the risk of laceration of the perineum, by bringing the weight 
of the child's head to bear more directly upon it. Thus Schroeder 
found that lacerations occurred in 37.6 per cent, of cases delivered on 
the back, as against 24.4 per cent, in other positions. 

The patient usually remains in bed during the whole of this stage, 
and it is customary for the nurse to tie to the foot of the bed a jack- 
towel, which is laid hold of and used as a support in making bearing- 
down efforts. If the pains be few and far between, and the patient 
finds it more comfortable to get up occasionally, there is no reason 
why she should not do so. On the contrary, as we shall subsequently 
see, in treating of lingering labor, the pains under such circumstances 
are often increased in the sitting posture in consequence of the weight 
of the child producing increased pressure on the nerves of the vagina. 

At this time vaginal examination, which should be more frequently 
repeated than in the first stage, enables us to ascertain precisely the 
position of the head, by means of the sutures and fontanelles, as well 
as to watch its progress. 

It not unfrequently happens that the head descends into the pelvis, 
even to its floor, without the os having entirely disappeared. The 
anterior lip especially is apt to get caught between the head and pubes, 
to become swollen by the pressure to which it is subjected, and thus 
to retard the progress of the labor. There can be no reasonable 
objection to attempting to prevent this cause of delay by pressing on 



MANAGEMENT OF NATURAL LABOR. 303 

the incarcerated lip during* the interval of the pains, so as to push it 
above the head, and maintain it there during the pains until the head 
descends below it. This manoeuvre, if done judiciously, and without 
any undue roughness or force, is certainly not liable to be attended by 
any of the evil consequences which many obstetricians have attributed 
to it ; it is indeed a matter of common sense that the injury to the 
cervix is likely to be less if it be pushed gently out of the way than 
if it be left to be tightly jammed for hours between the presenting 
part and the bony pelvis. This mode of assistance is very different 
from the digital dilatation of a rigid cervix, which was formerly much 
practised, especially iu Edinburgh, in consequence of the recommenda- 
tion of Hamilton, and which was properly objected to by the great 
majority of obstetricians. 

If the pains be producing satisfactory progress, no further inter- 
ference is required. The medical attendant should, however, see that 
the bladder is evacuated ; and if it have not been so for some hours, 
it may be necessary to draw off the urine by the catheter. Whenever 
the labor is lengthy, he should occasionally practise auscultation, so as 
to satisfy himself that the foetal circulation is being satisfactorily 
carried on. 

The regulation of the bearing-down efforts at this time is of impor- 
tance. It is common for the nurse to urge the patient to help herself 
by straining, and it is certain that by voluntary action of this kind 
she can materially increase the action of the accessory muscles of par- 
turition. If the pains be strong, and the labor promise to be rapid, 
such voluntary exertions are not likely to be prejudicial. On the 
other hand, if the case be progressing slowly, they only unnecessarily 
fatigue the patient, and should be discouraged. AVhen the perineum 
is distended we may even find it advisable to urge the patient to cease 
all voluntary effort, and to cry out, for the express purpose of lessen- 
ing the tension to which the perineum is subjected. This is the stage 
in which anaesthesia is most serviceable, but its employment must be 
separately discussed. 

Distention of the Perineum. — As the head descends more and 
more the perineum becomes distended, and there is considerable differ- 
ence of opinion amongst accoucheurs as to the management of the case 
at this time. In most obstetric works the practitioner is advised to 
endeavor to prevent laceration by the manoeuvre that is described as 
supporting the perineum. By this is meant, laying the palm of the 
hand on the distended structures, and pressing firmly upon them 
during the acme of the pain, with the view of mechanically pre- 
venting their tearing. There can be little doubt that this, or some 
modification of it, is the practice followed by the large majority of 
practitioners. Of late years the evil effects likely to attend it have 
been specially dwelt upon by Graily Hewitt, Leishman, Goodell, and 
other writers, who maintain that by pressure exerted in this fashion 
we not only fail to prevent, but actually favor, laceration, in conse- 
quence of the pressure producing increased uterine action, just at the 
time when forcible distention of the perineum is likely to be hurtful. 
Therefore some hold that the perineum ought to be left entirely alone, 



304 LABOR. 

and that the head should be allowed gradually to distend it, without 
any assistance on the part of the practitioner. 

Much error may be traced to a misconception of what is required. 
The term "supporting the perineum" conveys an unquestionably 
erroneous idea, and it is certain that no one can prevent laceration by 
mechanical support. If the term relaxation of the perineum were em- 
ployed, we should have a far more accurate idea of Avhat should be 
aimed at, and, if this be borne in mind, I think it cannot be ques- 
tioned that Nature may be most usefully assisted at this stage. 

Dr. Goodell, of Philadelphia, has specially studied this subject, and 
has recommended a method the object of which is to relax the peri- 
neum. His advice is, that one or two fingers of the left hand should 
be inserted into the rectum, by which the perineum should be hooked 
up and pulled forward over the head, toward the pubes, the thumb of 
the same hand being placed on the advancing head, so as to restrain 
its progress if needful. I have adopted this plan frequently, and 
believe that it admirably answers its purpose, especially when the peri- 
neum is greatly distended, and laceration is threatened. It must be 
admitted that the insertion of the fingers into the anal orifice, in the 
manner recommended, is repugnant both to the practitioner and 
patient, and the same result can be obtained in a less unpleasant way. 
I mention it, however, to show what it is that the practitioner must 
aim at. If, when the head is distending the perineum greatly, the 
thumb and forefinger of the right hand are placed along its sides, it 
can be pushed gently forward over the head at the height of the pain, 
while the tips of the fingers may, at the same time, press upon the 
advancing vertex, so as to retard its progress if advisable (Fig. 109). 
By this means the sudden and forcible stretching of the perineal struc- 
tures is prevented, and the chance of laceration reduced to a minimum, 
while Nature's mode of relaxing the tissues, by dilatation of the 
anal orifice, is favored. This is very different from the mechanical 
support that is usually recommended, and the less pressure that is 
applied directly to the perineum the better. Nor is it either needful or 
advisable to sit by the patient with the hand applied to the perineum 
for hours, as is so often practised. Time should be given for the 
gradual distention of the tissues by the alternate advance and recession 
of the head, and we need only intervene to assist relaxation when the 
stretching has reached its height, and the head is about to be expelled. 
A napkin may be interposed between the hand and the skin, for the 
purpose of cleanliness. Should the perineum be excessively tough and 
resistant, assiduous fomentation with a hot sponge may be resorted to, 
and will be of some service in promoting relaxation. 

Incision of the Perineum. — When the tension is so great that 
laceration seems inevitable, it is generally recommended that a slight 
incision should be made on each side of the central raphe, with the 
view of preventing spontaneous laceration. This may no doubt be 
done with perfect safety, but I question if it is likely to be of use. 
The idea is that an incised wound is likely to heal more readily than 
a lacerated one. When, however, a distended perineum ruptures, its 
structures are so thinned that the tear is always linear; and, as a 



MANAGEMENT OF NATURAL LABOR. 



305 



matter of fact, the edges of the tear are always as clean, and as closely 
in apposition, as if the cut had been made with a knife. Moreover, 
the laceration invariably heals perfectly, if only the edges be brought 
into contact at once with one or two sutures. I believe, therefore, that 
Goodell is right in stating that incision of the perineum is rarely, if 
ever, necessary, unless it is hardened by previous cicatrization. In 
almost all first labors the fourchette is torn, but requires no treatment 

Fig. 109. 




Mode of effecting relaxation of the perineum. 



of any kind. In some cases, do what we will, more or less laceration 
occurs, and the perineum should always be examined after the expul- 
sion of the child, to see if any tear has taken place. 

If it has given way to any extent, I believe that it is good practice 
to insert one or two interrupted sutures of silver wire or chromic gut 
at once. Immediately after delivery the sensibility of the tissues is 
deadened by the distention to which they have been subjected, and the 
sutures can be inserted with little or no pain. It is quite true that 
lacerations of an inch or less will generally heal perfectly well of them- 
selves; but this is not invariably the case, while healing almost cer- 
tainly follows if the edges be brought together at once. In the severer 
forms of laceration, extending back to, or even through, the sphincter, 
the precaution is all the more necessary, and a subsequent operation of 
gravity may in this way be avoided. The sutures can be removed 
without difficulty in a week or so, when complete adhesion has taken 
place. 

Expulsion of the Child. — The head, when expelled, should be 
received in the palm of the right hand, while the left hand is placed 
upon the abdomen to follow down the uterus as it contracts and expels 
the body. There is generally some little delay after the expulsion of 
the head, and we should now sec if the cord surround the neck, and, 

20 



306 LABOR. 

if it does so, it should be drawn over the head, and, if this is not pos- 
sible, it may be tied and divided between the ligatures, The expulsion 
of the body should be left entirely to the uterine contractions. If 
there be undue delay Ave may endeavor to excite uterine action by fric- 
tion on the fundus, and it will rarely happen that sufficient contraction 
does not now come on. If we display undue haste in withdrawing 
the body, w r e run the risk of emptying the uterus while its tissues are 
relaxed, and so favor hemorrhage. If, however, there seems serious 
danger of the child being asphyxiated, its expulsion may be favored 
by gently passing the forefinger of each hand within the axillae, and 
using traction ; but it is only very exceptionally that such interference 
is required. 

Promotion of Uterine Contraction after the Birth of the 
Child. — As the uterus contracts, it should be carefully followed down 
through the abdominal parietes by the left hand, which should grasp 
it as the body is expelled, with the view of seeing that it is efficiently 
contracted. This is a point of vital importance in preventing hemor- 
rhage, which will presently be more especially considered. 

As soon as the child cries we may proceed to tie and separate the 
cord. For this purpose the nurse usually provides ligatures composed 
of several strands of whitey-brown thread; but tape, or any other 
suitable material, may be employed. It is important, especially if the 
cord be very thick and gelatinous, to see that it is thoroughly com- 
pressed, so that the vessels are obliterated, otherwise secondary hemor- 
rhage might occur. The cord is tied about an inch and a half from 
the child, and it is usual, though, of course, not essential, to place a 
second ligature about two inches nearer the placental extremity of the 
cord. The latter is, perhaps, of some use by retaining the blood, and 
thus increasing the size of the placenta, and favoring its more ready 
expulsion by uterine contraction. The cord is then divided with 
scissors between the ligatures, the child wrapped up in flannel, and 
given to the nurse, or to a bystander, to hold, while the attention of 
the practitioner is concentrated on the mother, with a view to the 
proper management of the third stage of labor. The researches of 
Buclin, 1 Ribemont, 2 and others show that there is a distinct advantage 
in not tying the cord until the child has cried lustily, as the act of 
respiration tends to withdraw the placental blood, and thus increases 
the entire amount of blood in the foetus. It is said that after late 
ligature of the cord the child is more vigorous and active than when 
it is tied too early. 

The cord may, if preferred, be treated with perfect safety by lacera- 
tion. This method was first brought under my notice by the late Dr. 
Stephen, who employed it for many years, and in several hundred 
cases. The cord is twisted round the index fingers of both hands, and 
torn through, the lacerated vessels retracting without any hemorrhage. 
It is a close imitation of the method instinctively adopted by the 
lower animals, who gnaw the cord asunder, and has the advantage of 

1 Budin : Progres Medical, torn. iv. pp. 2, 36. 

2 Archiy de Tocologie, 1879, p. 577. 



MANAGEMENT OF NATURAL LABOR. 307 

dispensing' with ligatures altogether. I have used it myself in a large 
number of cases, but prefer, on the whole, the plan usually adopted. 

Importance of Proper Management of Third Stage. — There is 
unquestionably no period of labor where skilled management is more 
important, and none in which mistakes are more frequently made. 
By proper care at this time the risk of post-partum hemorrhage is 
reduced to a minimum, the efficient contraction of the uterus is secured, 
the amount and intensity of after-pains are lessened, and the safety and 
comfort of the patient greatly promoted. Moreover, the general prac- 
tice, as to the management of this stage, is opposed to the natural 
mechanism of placental expulsion, and is far from being well adapted 
to secure the important objects which we ought to have in view. Let 
us see what is the practice usually recommended and followed, and 
then Ave shall be in a position to understand in what respects it is 
erroneous. For this purpose I cannot do better than copy the direc- 
tions contained in one of our most deservedly popular obstetric text- 
books, which undoubtedly expresses the usual practice in the manage- 
ment of this stage : " When the binder is applied, the patient may be 
allowed to rest a while, if there is no flooding; after which, when the 
uterus contracts, gentle traction may be made by the funis, to ascertain 
if the placenta be detached. If so, and especially if it be in the 
vagina, it may be removed by continuing the traction steadily in the 
axis of the upper outlet at first, at the same time making pressure on 
the uterus." ' 

This may fairly be taken as a sufficiently accurate description of the 
practice which was formerly usually followed. 2 The objections I have 
to make are : 1. That it inculcates the common error of relying ou the 
binder as a means of promoting uterine contraction, advising its appli- 
cation before the expulsion of the placenta ; while I hold that the 
binder should never be applied until after the placenta is expelled, and 
not even then, unless the uterus is perfectly and permanently con- 
tracted. 2. That it teaches that traction on the cord should be used 
as a means of withdrawing the placenta ; whereas the uterus itself 
should be made to expel the afterbirth, and in nineteen cases out of 
twenty, the finger need uever be introduced into the vagina after the 
birth of the child, nor the cord touched. This may seem an exagger- 
ated statement to those who have accustomed themselves to the former 
method of dealing with the placenta; but I feel confident that all who 
have learnt the method of expression of the placenta would testify to 
its accuracy. 

Expression of the Placenta : Its Object — The cardinal point to 
bear in mind is, that the placenta should be expelled from the uterus 
bv a 1718 a tergo, not drawn out by a vis a f route. That uterine pressure 
after the birth of the child has been recommended by many English 
writers is certain, and the Dublin school especially have dwelt on its 
importance as a preventive of post-partum hemorrhage ; but the dis- 

i Churchill's Theory and Practice of Midwifery, p. 162. 

2 This practice is further illustrated by the annexed diagram, contained in most obstetric works, 
which represents the accoucher as withdrawing the placenta by traction, and which I insert as 
an illustration of what ougbt not to be done (Fig 110). 



308 



LABOR. 



tinct enunciation of the doctrine that the placenta should be pressed, 
and not drawn out of the uterus, we owe to Crede and other German 
writers ; and it is only of late years that this practice has become at 
all common. Those who have not seen placental expression practised 
find it difficult to understand that, in the large majority of cases, the 
uterus may be made to expel the placenta out of the vagina ; but such 



Fig. no. 




Usual method of removing the placenta by traction on the cord. 

Is unquestionably the fact. A little practice is no doubt necessary to 
effect this satisfactorily ; but when once the knack has been learned, 
there is little difficulty likely to be experienced. 

Before describing the method of placental expression, a word of 
caution may be said against undue haste in attempting expression of 
the placenta, a mistake that is often made, and which, I believe, tends 
to increase the risk of post-partum hemorrhage. So long as we satisfy 
ourselves that the uterus is fairly contracted so as to avoid the possi- 
bility of its distention with blood, a certain delay after the birth of the 
child is useful, from its giving time for coagula to form within the 
uterine sinuses, by which their open mouths are closed up. The im- 
portance of this point has been specially dwelt upon by McClintock, 
who lays down the rule that fifteen or twenty minutes should be allowed 
to elapse after the birth of the child, before any attempt to remove the 
afterbirth is made. This is a good and safe practical rule, as it gives 
ample time for the complete detachment of the placenta and the coagu- 
lation of the blood in the uterine sinuses. 

During this interval the practitioner or nurse should sit by the bed- 
side, with the hand on the uterus to secure contraction and prevent dis- 
tention; but not kneading or forcibly compressing it. When we judge 
that a sufficient time has elapsed, we may proceed to effect expulsion, 



MANAGEMENT OF NATURAL LABOR. 



309 



For this purpose the fundus should be grasped in the hollow of the 
left hand, the ulnar edge of the hand being well pressed down behind the 
fundus, and, when the utenis is felt to harden, strong and firm pressure 
should be made downward and backward in the axis of the pelvic brim. 
If this manoeuvre be properly carried out, and sufficiently firm pressure 
made, in almost every case the uterus may be made to expel the placenta 
into the bed, along with any coagula that may be in its cavity (Fig. 



Fig. 111. 




Illustrating expression of the placenta. 



Ill), The uterine surface of the placenta is generally expelled first, as 
is represented in the diagram, the cord being within the membranes ; 
whereas the festal surface, and root of the cord, are the parts which 
appear first when the placenta is removed by traction (Fig. 110). If 
we do not succeed at the first effort, which is rarely the case if extru- 
sion be not attempted too soon after the birth of the child, we may wait 
until another contraction takes place, and then reapply the pressure. 
I repeat that, after a little practice, the placenta may be entirely ex- 
pelled in this way, in nineteen cases out of twenty, without even touch- 
ing the cord, and the bugbear of retained placenta will cease to be a 
source of dread. 

Should we fail in causing the uterus to expel the placenta, a vaginal 
examination may be made, and, if the placenta be found lying entirely 
in the vagina, it may be carefully withdrawn. If, however, the cord 
can be traced up through the os, showing that the placenta is still 
within the uterine cavity, we must again resort to pressure to effect its 
expulsion, and not attempt to withdraw it by traction. Such cases 
may fairly be classed as retained placenta, but they should be very 
rarely met with, and are discussed elsewhere. When they do occur 
often in the hands of the same practitioner, it is fair to conclude that 
he has not properly acquired the art of managing this stage of labor. 
Generally speaking, the placenta should be expelled within twenty 
minutes after the birth of the child ; but no doubt, in the large ma- 



310 LABOR. 

jority of cases, expulsion might be effected sooner were it advisable to 
attempt it. 

Management of the Membranes. — When the mass of the placenta 
is expelled, the membranes generally still remain in the vagina, and 
they should be twisted into a rope, and very gently withdrawn, so as 
not to leave any portion behind. This is a precaution the importance 
of which I would strongly urge, for I believe that the chance of part 
of the membranes being torn off and left in utero is the one objection 
to the method recommended. With due care, however, this accident 
may be avoided, and the risk will be lessened if the placenta is received 
into the palm of the right hand, on expression, so as to avoid any 
strain on the membranes. 

The duties of the medical attendant are not even now over. For 
at least ten minutes after the extrusion of the placenta, he should keep 
his hand on the firmly contracted uterus, gently kneading it, without 
any force, for the purpose of promoting firm and equable contraction, 
and causing it to throw off the coagula that may form in its cavity. 

The subsequent comfort and safety of the patient may be promoted 
by administering at this time a full dose of ergot of rye, such as a 
drachm, or more, of the liquid extract. The property possessed by 
this drug of producing tonic and persistent contraction of the uterine 
fibres, which renders it of doubtful utility as an oxytocic during labor, 
is of special value after delivery, when such contraction is precisely 
what we desire. I have long been in the habit of administering the 
drug at this period, and believe it to be of great value, not only as a 
prophylactic against hemorrhage, but as a means of lessening after- 
pains. 

Examination of the Placenta. — The accoucheur should always 
satisfy himself as to the integrity of the placenta, and not be satisfied 
with the report of the nurse. It should be carefully examined in 
every case, to make sure that no portion of it, nor of the membrane, is 
left behind. It is well to re-invert the membranes, and examine the 
uterine surface of the placenta in the first instance, and then to satisfy 
oneself that the membranes, both chorion and amnion, are entire. If 
any portion is absent, it must be carefully searched for in the clots, or 
in the vagina or uterine cavity. Should it be necessary to introduce 
the finger or hand for this purpose, even when carefully asepticized, 
the uterus should subsequently be washed out with a douche of hot 
water at 110° F., to which a few drops of creolin have been added, or 
with a solution of perchloride of mercury (1 : 2000), at the same 
temperature. 

Application of the Binder. — When we are satisfied that the uterus 
is permanently contracted, we may apply the binder, but this should 
rarely be done until at least half an hour after the birth of the child. 
The soiled clothes should be gently withdrawn from under the patient, 
moving her as little as possible, aud the binder should be, at the same 
time, slipped under the body, taking care that it is passed well below 
the hips so as to secure a firm hold. No kind of bandage is better 
than a piece of stout jean, of sufficient breadth to extend from the 
trochanters to the ensiform cartilage ; a jack-towel or bolster slip 



MANAGEMENT OF NATURAL LABOR. 311 

answers the purpose very well. These are preferable, at any rate at 
first, to the shaped binders that are often used. One or two folded 
napkins are generally placed over the uterus, so as to form a pad to 
keep up the pressure. Once in position, the binder is pulled tight, 
and fastened by pins. The utility of careful bandaging after delivery 
can scarcely be doubted, although some years ago it became the fashion 
to dispense with it. It gives a comfortable support to the lax abdom- 
inal walls, keeps up a certain amount of pressure on the uterus, and 
tends to restore the figure of the patient. After the bandage is 
applied, a warm antiseptic pad or napkin should be placed on the 
vulva, as a means of estimating the quantity of the discharge, and the 
patient may be allowed to rest. 

Examination of the Perineum. — In every case, especially in pri- 
iniparse, the perineum should be visually examined. This can easily be 
done after the placenta is expelled, without distressing the patient. If 
this precaution were habitually adopted many lacerations would be 
detected, which would otherwise escape observation. 

After-Treatment. — Unless the labor has been very long and fati- 
guing, an opiate, often exhibited as a matter of routine, is unadvisable ; 
although it may be well to leave one with the nurse, to be given if the 
patient cannot sleep, or if the after-pains be very troublesome. The 
practitioner may now leave the room, but not the house, and at least 
an hour should elapse after delivery before he takes his departure. 
Before doing so he should visit the patient, inspect the napkin to see 
that there is not too much discharge, and satisfy himself that the 
uterus is contracted, and not distended with coagula. He should also 
count the pulse, which, if the patient be progressing satisfactorily, will 
found at its normal average. If, however, it be beating over 100 per 
minute, he should on no account leave, for such a rapidity of the cir- 
culation renders it extremely probable that hemorrhage is impending. 
This is a good practical rule laid down by McClintock in his excellent 
paper " On the Pulse in Childbed," attention to w T hich may often save 
the patient from disastrous consequences. 

Before leaving, the practitioner should see that the room is darkened, 
all bystanders excluded, and the patient left as quiet as possible to 
recover from the shock of labor. 



312 LABOR 



OHAPTEE IV. 

ANESTHESIA IN LABOE. 

A few words may be said as to the use of anaesthetics during labor, 
a practice which has become so universal that no argument is required 
to establish its being a perfectly legitimate means of assuaging the suf- 
ferings of childbirth. Indeed the tendency in the present day is in 
the opposite direction ; and a common error is the administration of 
chloroform to an extent which materially interferes with the uterine 
contractions and predisposes to subsequent post-partum hemorrhage. 

Agents Employed. — Practically speaking, the only agent hitherto 
employed in this country is chloroform, although the bichloride of 
methylene, and ether, have been occasionally tried. Of late years, 
chloral has been extensively used by some ; and as I believe it to be 
an agent of very great value, I shall first indicate the circumstances 
under which it may be employed. 

Chloral. — The peculiar value of chloral in labor is, that it may be 
safely administered at a time when chloroform cannot be generally 
employed. The latter, while it annuls suffering, very frequently 
tends, in a marked degree, to diminish uterine action. This is a 
familiar observation to all who have employed it much during labor, 
as the diminution of the force and intensity of the pains, and the con- 
sequent retardation of the labor, often oblige us to supend its inhala- 
tion, at least temporarily. Indeed, this very property of annulling 
uterine action is one of its most valuable qualities in obstetrics, as in 
certain cases of turning. For such purposes it is necessary to give it 
to the surgical extent, which we endeavor to avoid when it is used 
simply to lessen the suffering of ordinary labor. Still it is not always 
easy to limit its action in this way, and thus it very frequently does 
more than we wish. Such diminution in the intensity of uterine con- 
traction is comparatively of less consequence in the propulsive stage, 
and it is generally more than counterbalanced by the relief it affords. 
In the first stage it is otherwise, and, practically speaking, chloroform 
is generally not admissible until the head is in the pelvic cavity. 

Chloral, on the other hand, has no such relaxing effects on uterine 
contraction. It cannot, it is true, compete with chloroform in its 
power of relieving pain, but it produces a drowsy state in which the 
pain is not felt nearly so acutely as before. It is, therefore, in the 
first stage of labor, while the pains are cutting and grinding, and 
during the dilatation of the cervix, that it finds its most useful appli- 
cation. It is especially valuable in those cases, so frequently met 
with in the upper classes, in which the pains produce intolerably 
acute suffering, but with little effect on the progress of the labor. In 
them the os is often thin and rigid, and the pains very frequent and 
acute, but little or no dilatation is effected. When the patient is brought 
under the influence of chloral, however, the pains become less frequent 



ANAESTHESIA IN LABOR. 313 

but stronger, nervous excitement is calmed, and the dilatation of the 
cervix often proceeds rapidly and satisfactorily. Indeed, I know of 
nothing which answers so well in cases of rigid, undilatable cervix, 
and I believe it to be far more effective, under such circumstances, 
than any of the remedies usually employed. 

The object is to produce a somnolent condition, which shall be pro- 
tracted as long as possible. For this purpose fifteen grains of chloral 
may be administered every twenty minutes, until three doses are 
given. This generally suffices to produce the desired effect. The 
patient becomes very drowsy, dozes between the pains, and wakes up 
as each contraction commences. It may be necessary to give a fourth 
dose at a longer interval, say an hour after the third dose, to keep up 
and prolong the soporific action ; but this is seldom necessary, and I 
have rarely given more than forty to fifty grains of chloral during the 
entire progress of labor. Another advantage of this treatment is that, 
while it does not interfere with the use of chloroform in the second 
stage, it renders it necessary to give less than otherwise would be 
called for, and thus its action can be more easily kept within bounds. 
On the whole, therefore, I am inclined to consider chloral a very 
valuable aid in the management of labor, and believe that it is 
destined to be much more extensively used than is at present the case. 
So far as my experience has yet gone, I have not met with any symptoms 
which have led me to think that it has produced bad effects ; and I 
have known many patients sleep quietly through labor, without ex- 
pressing any excessive suffering, or asking for chloroform, who, under 
ordinary circumstances, would have been most urgently calling for 
relief. It occasionally happens that the patient cannot retain the 
chloral, from its tendency to produce sickness ; it may then be readily 
given per rectum in the form of enema. 

Generally speaking, we do not think of giving chloroform until the 
os is fully dilated, the head descending, and the pains becoming pro- 
pulsive. It has often, indeed, been administered earlier, for the 
purpose of aiding the dilatation of a rigid cervix, and there is no 
doubt that it often succeeds well when employed in this way ; but I 
have already stated my belief that chloral answers this purpose better. 

There is one cardinal rule to be remembered in giving chloroform 
during the propulsive stage, and that is, that it should be administered 
intermittently, and never continuously. When the pain comes on a 
few drops may be scattered over a Skinner's inhaler, which affords one 
of the best means of administering it in labor, or placed within the 
folds of a handkerchief twisted into the form of a cone. During the 
acme of the pain the patient inhales it freely, and at once experieiv* s a 
sense of great relief; and, as soon as the pain dies away, the inhaler 
should be removed. In the interval between the pains the effect of 
the drug passes off, so that the higher degree of anaesthesia should 
never be produced. Indeed, when properly given, consciousness 
should not be entirely abolished, and the patient, between the pains, 
should be able to speak, and to understand what is said to her. This 
intermittent administration constitutes the peculiar safety of chloro- 
form administered in labor, and it is a fortunate circumstance that 



314 LABOR. 

there are very few cases on record of death during the inhalation of 
chloroform for obstetric purposes. This is obviously due to the effect 
of each inhalation passing off before a fresh dose is administered. 

The effect on the pains should be carefully watched. If they 
become very materially lessened in force aud frequency, it may be 
necessary to stop the inhalation for a short time, commencing again 
when the pains get stronger ; this effect may be often completely and 
easily prevented by mixing the chloroform with about one-third of 
absolute alcohol, which, originally recommended, I believe, by Dr. 
Sansom, increases the stimulating effects of chloroform, and thus 
diminishes its tendency to produce undue relaxation. The amount 
administered must vary, of course, with the peculiarities of each indi- 
vidual case and the effect produced, but it need never be large. As 
the head distends the perineum, and the pains get very strong and 
forcing, it may be given more freely and to the extent of inducing 
even complete insensibility just before the child is born. 

Ether. — In cases in which chloroform has lessened the force of the 
pains, ether may be given instead with great advantage. It certainly 
often acts well when chloroform is inadmissible on account of its effects 
on the pains, and, so far as my experience goes, it has not the property 
of relaxing the uterus, but, on the contrary, has sometimes seemed to 
me distinctly to intensify the pains. Of late I have used a mixture of 
one part of absolute alcohol, two of chloroform, and three of ether. 
This is less disagreeable than ether, and has not the over-relaxing 
effects of chloroform, and, on the whole, I believe it to be the best 
anaesthetic for midwifery practice. 

Bearing in mind the tendency of chloroform to produce uterine 
relaxation, more than ordinary precautions should always be taken 
against post-partum hemorrhage in all cases in which it has been freely 
administered. 

In cases of operative midwifery, it is often given to the extent of 
producing complete anaesthesia. In all such cases it should be admin- 
istered, when possible, by another medical man and not by the operator, 
because the giving of chloroform to the surgical degree requires the 
undivided attention of the administrator, and no man can do this and 
operate at the same time. I once learnt an important lesson on this 
point. I had occasion to apply the forceps in the case of a lady who 
insisted on having chloroform. When commencing the operation I 
noticed some suspicious appearances about the patient, who was a large 
stout woman, with a feeble circulation. I therefore stopped, allowed 
her to regain consciousness, and delivered her without anaesthesia, 
much to her own annoyance. Just one month after labor she went to 
a dentist to have a tooth extracted, and took chloroform, during the 
inhalation of which she died. This impressed on my mind the lesson 
that no man can do two things at the same time. The partial uncon- 
sciousness of incomplete anaesthesia, in which the patient is restless and 
tossing about, renders the application of forceps, as well as all other 
operations, very difficult. Therefore, unless the patient can be com- 
pletely and fully anaesthetized, it is better to operate without chloroform 
being given at all. 



PELVIC PRESENTATION'S. 315 



CHAPTEE Y. 

PELVIC PRESENTATIONS. 

Under the head of pelvic presentations it is customary to include all 
cases in which any part of the lower extremities of the child presents. 
By some these are further subdivided into breech, footling, and knee 
presentations ; but, although it is of consequence to be able to recognize 
the feet and the knee when they present, so far as the mechanism and 
management of delivery are concerned, the cases are identical, and, 
therefore, may be most conveniently considered together. 

Frequency. — Presentations coming under this. head are far from 
uncommon ; those in which the breech alone occupies the pelvis are 
met with, according to Churchill, once in fifty-two labors, while Rams- 
botham estimates that it presents more frequently, viz., once in 38.8 
labors. Footling presentations occur only once in ninety-two cases. 
They are probably often the mere conversion of original breech pres- 
entations, the feet having come down during the labor, either in con- 
sequence of the sudden escape of the liquor amnii, when the breech was 
still freely movable above the brim, or from some other cause. Knee 
presentations are extremely rare, as may be readily understood if it be 
borne in mind that to admit them the thighs must be extended, hence 
the vertical measurement of the child must be greatly increased, and 
therefore it could not be readily accommodated within the uterine 
cavity, unless of unusually small size. As a matter of fact, Mine. La 
Chapelle found only one knee presentation in upward of 3000 cases. 

The causes of pelvic presentations are not known. They are 
probably the same as those which produce other varieties of mal- 
presentations, especially an excess of liquor amnii and slight pelvic 
contraction ; and it is not unlikely that, in certain women, there may 
be some peculiarity in the shape of the uterine cavity which favors 
their production. It would be difficult otherwise to explain such a 
case as that mentioned by Velpeau, in which the breech presented in 
six labors. 

Prognosis. — The results, as regards the mother, are in no way more 
unfavorable than in vertex presentation. The first stage of the labor 
is generally tedious, since the large rounded mass of the breech does 
not adapt itself so well as the head to the lower segment of the uterus, 
and dilatation of the cervix is consequently apt to be retarded. The 
second stage is, however, if anything, more rapid than in vertex cases ; 
and even when it is protracted, the soft breech does not produce such 
injurious pressure on the maternal structures as the hard and unyield- 
ing head. 

The result is very different as regards the child. Dubois calculated 



316 LABOR. 

that one out of eleven children was stillborn. Churchill estimates the 
mortality as much higher, viz., one in three and one-fifth. The latter 
certainly indicates a larger number of stillbirths than is consistent 
with the experience of most practitioners, and more than should occur 
if the cases be properly managed ; but there can be no doubt that the 
risk to the child is, even under the most favorable circumstances, very 
great. Even when the child is not lost, it may be seriously injured. 
Dr. Kuge has tabulated a series of twenty-nine cases in which there 
were found to be fractures of bones or other injuries. 

The chief source of danger is pressure on the umbilical cord, in the 
interval elapsing between the birth of the body and the head. At this 
time the cord is very generally compressed between the head of the 
child and the pelvic walls, so that circulation in its vessels is arrested. 
Hence the aeration of the foetal blood cannot take place ; and, pul- 
monary respiration not having been yet established, the child dies 
asphyxiated. There are other conditions present which tend, although 
in a minor degree, to produce the same result. One of these is that 
the placenta is probably often separated by the uterine contractions 
when the bulk of the body is being expelled, as, indeed, takes place 
under analogous circumstances when the vertex presents ; the necessary 
result being the arrest of placental respiration. Joulin thinks that 
the same effect may be produced by the compression of the placenta 
between the contracted uterus and the hard mass of the foetal skull. 
Probably all these causes combine to arrest the functions of the pla- 
centa; and, if the delivery of the head, and consequently the establish- 
ment of pulmonary respiration, be delayed, the death of the child is 
almost inevitable. The corollary is that the danger to the child is in 
direct proportion to the length of time that elapses between the birth 
of the body and that of the head. 

The risk to the child is greater in footling than in breech cases, 
because in the former the maternal structures are less perfectly dilated, 
in consequence of the small size of the feet and thighs, and, therefore, 
the birth of the head is more apt to be delayed. 

Diagnosis. — Inasmuch as the long axis of the child corresponds 
with the long axis of the uterus in pelvic, as in vertex presentations, 
there is nothing in the shape of the uterus to arouse suspicion as to the 
character of the case. Still it is often sufficiently easy to recognize a 
pelvic presentation by abdominal examination, if we have occasion to 
make one. The facility with which it may be done depends a good 
deal on the individual patient. If she be not very stout, and if the 
abdominal parietes be lax and non-resistant, we shall generally be 
able to feel the round head at the upper part of the uterus, much firmer 
and more defined in outline than the breech. The conclusion will be 
fortified if we hear the foetal heart beating on a level with, or above, 
the umbilicus. The greater resistance on one side of the abdomen will 
also enable us to decide, with tolerable accuracy, to which side the 
back of the child is placed. Information thus acquired is, at the best, 
uncertain ; and we can never be quite sure of the existence of a pelvic 
presentation until we can corroborate the diagnosis by vaginal exam- 
ination. 



PELVIC PRESENTATIONS. 317 

The first circumstance to excite suspicion on examination per 
vaginam, even when the os is undilated, is the absence of the hard 
globular mass felt through the lower segment of the uterus, so charac- 
teristic of vertex presentations. AVhen the os is sufficiently open to 
allow the membranes to protrude, although the presenting part is too 
high up to be within reach, we may be struck with the peculiar shape 
of the bag of membranes, which, instead of being rounded, projects a 
considerable distance through the os, like the finger of a glove. This 
is a peculiarity met with in all malpresentations alike, and is, indeed, 
much less distinct in breech than in footling presentations, because in 
the former the membranes are more stretched, just as they are in vertex 
cases. When the membranes rupture, instead of the waters dribbling 
away by degrees, they often escape with a rush, in consequence of the 
pelvic extremity not filling up the lower part of the uterus so accu- 
rately as the head, which acts as a sort of ball-valve, and prevents the 
sudden and complete discharge of the waters. 

Often on first examining, even when the membranes are ruptured, 
the presentation is too high up to be made out accurately. All that 
we can be certain of is, that it is not the head ; and the case must be 
carefully watched, and examinations frequently repeated, until the 
precise nature of the presentation can be established. If the breech 
present, the finger first impinges on a round, soft prominence, on 
depressing which a bony protuberance, the tuber ischii, can be felt. 
On passing the finger upward it reaches a groove beyond which a 
similar fleshy mass, the other buttock, can be felt. In this groove 
various characteristic points, diagnostic of the presentation, can be 
made out. Toward one end we can feel the movable tip of the coccyx, 
and above it the hard sacrum, with its rough projecting prominences. 
These points, if accurately made out, are quite characteristic, and re- 
semble nothing in any other presentation. In front there is the anus, 
in which it is sometimes, but by no means always, possible to insert 
the tip of the finger. If this can be done, it is easy to distinguish it 
from the mouth, with which it might be confounded, by observing 
that the hard alveolar ridges are not contained within it. Still more 
in front we may find the genital organs, the scrotum in male children 
being often much swollen if the labor has been protracted. Thus it is 
often possible to recognize the sex of the child before birth. 

The breech might be mistaken for the face, especially if the latter 
be much swollen ; but this mistake can readily be avoided by feeling 
the spinous processes of the sacrum. 

The knee is recognized by its having two tuberosities with a depres- 
sion between them. It might be confounded with the heel, the elbow, 
or the shoulder. From the heel it is distinguished by having two 
tuberosities instead of one ; from the elbow, by the latter having one 
sharp tuberosity, with a depression on one side, instead of a central 
depression and two lateral prominences ; and from the shoulder, by 
the latter being more rounded, having only one prominence, running 
from which the acromion and clavicle can be traced. 

The foot may be mistaken for the hand. This error will be avoided 
by remembering that all the toes are in the same line, and that the 



318 LABOR. 

great toe cannot be brought into apposition with the others, as the 
thumb can with the fingers. The internal border of the foot is much 
thicker than the external, whereas the two borders of the hand are of 
the same thickness. Moreover, the foot is articulated at right angles 
to the leg, and cannot be brought into a line with it, as the hand can 
with the arm. Finally, the projection of the calcaneum is character- 
istic, and resembles nothing in the hand. 

Mechanism. — As is the case in other presentations, obstetricians 
have very variously subdivided breech presentations, with the effect of 
needlessly complicating the subject. The simplest division, and that 
which will most readily impress itself on the memory of the student, 
is to describe the breech as presenting in four positions, analogous to 
those of the vertex, the sacrum being taken as representing the occiput, 
and the positions being numbered according to the part of the pelvis 
to which it points. Thus we have — 

First, or left sacro-anterior (sacro-lseva anterior, s.L.A., correspond- 
ing to the first position of the vertex). The sacrum of the child points 
to the left foramen ovale of the mother. 

Second, or right sacro-anterior (sacro-dextra anterior, s.d.a., corre- 
sponding to the second vertex position). The sacrum of the child 
points to the right foramen ovale of the mother. 

Third, or right sacro-posierior (sacro-dextra posterior, s.d.p., corre- 
sponding to the third vertex position). The sacrum of the child points 
to the right sacro-iliac synchondrosis of the mother. 

Fourth, or left sacro-posterior (sacro-lseva posterior, s.l.p,, corre- 
sponding to the fourth vertex position). The sacrum of the child 
points to the left sacro-iliac synchondrosis of the mother. 

Of these, as with the corresponding vertex positions, the first (s.L.A.) 
and third (s.d.p.) are the most common, their comparative frequency, 
no doubt, depending on the same causes. The mechanical conditions 
to which the presenting part is subjected are also identical, but the 
alterations of position of the breech in its progress are by no means so 
uniform as those of the head, on account of its less perfect adaptation 
to the pelvic cavity. The mechanism of the delivery of the shoulders 
and head in breech presentations, moreover, is of much greater prac- 
tical importance than that of the body in vertex presentations, inas- 
much as the safety of the child depends on its speedy and satisfactory 
accomplishment. Bearing these facts in mind, it will suffice to describe 
briefly the phenomena of delivery in the first (s.L.A.) and third (s.d.p.) 
breech positions. 

Position of the Child at Brim. — In the first position (s.L.A.) (Fig. 
112) the sacrum of the child points to the left foramen ovale; its back 
is consequently placed to the left side of the uterus and anteriorly, and 
its abdomen looks to the right side of the uterus and posteriorly. The 
sulcus between the buttocks lies in the right oblique diameter of the 
pelvis, while the transverse diameter of the buttocks lies in the left 
oblique diameter, the left buttock being most easily within reach. As 
in vertex presentations, the hips of the child lie on the same level at the 
pelvic brim, although Naegele describes the left hip as placed lower- 
than the right. 



PELVIC PRESENTATIONS. 



319 



As the pains act on the body of the child, the breech is gradually 
forced through the pelvic cavity, retaining the same relations as at the 
brim, its progress being generally more slow than that of the head, 
until it reaches the lower pelvic strait, when the same mechanism which 
produces rotation of the occiput comes to operate upon it. The result 
is a rotation of the child's pelvis, so that its transverse diameter comes 
to lie approximately in the antero-posterior diameter of the outlet, its 
antero-posterior diameter corresponds to the transverse diameter of the 
mother's pelvis, the left hip lies behind the pubes, and the right toward 
the sacrum. This rotation, which is admitted by the majority of obste- 
tricians, is altogether denied by Xaegele. There can be no doubt, 
however, that it does generally take place, but by no means so con- 
stantly as the corresponding rotation of the vertex ; and it is not 
uncommon for it to be entirely absent, and for the hips to be born in 
the oblique diameter of the outlet. The body of the child is said fre- 
quently not to follow the movement imparted to the hips, so that there 
is more or less of a twist in the vertebral column. 

The left hip now becomes firmly fixed behind the pubes, and a 
movement of extension, analogous to that of the head in vertex pres- 
entations, takes place. The right, or posterior, hip revolves around 
the fixed one, gradually distends the perineum, and is expelled first, 

Fig. 112. 




First, or left sacroanterior position (s.l.a.) of the breech. (After Farabeuf.) 

the left hip rapidly following. As soon as both hips are born, the feet 
slip out, unless the legs are completely extended upon the child's abdo- 
men. The shoulders soon follow, lying in the left oblique diameter 
of the pelvis (Fig. 113). 1 The left shoulder rotates forward behind 



1 This figure, however, represents the position of the shoulders in the second (s. d. a.) position. 



320 



LABOR, 



the pubes, where it becomes fixed, the right shoulder sweeping over 
the perineum, and being born first. The arms of the child are gener- 
ally found placed upon its thorax, and are born before the shoulders. 



Fig. 113. 




Passage of the shoulders and partial rotation of the thorax. 



Fig. 114. 




Third, or right sacro-posterior position (s.d.p.) of the breech. (After Farabeuf.) 

Sometimes they are extended over the child's head, thus causing con- 
siderable delay, and greatly increasing the risk to the child. It is 
now generally admitted that such extension is most apt to occur when 
traction has been made on the child's body with the view of hastening 
delivery, and that it is rarely met with when the expulsion of the body 
is left entirely to the normal powers. 



PELVIC PRESENTATIONS, 321 

Delivery of the Head. — "When the shoulders are expelled the head 
enters the pelvis in the opposite, or right oblique diameter, the face 
looking to the right saero-iliac synchondrosis. As the greater part of 
the child is now expelled, and as the head has entered the vagina, the 
uterus, having a comparatively small mass to contract upon, must 
obviously act at a mechanical disadvantage. Still the pressure of the 
head on the vagina is a powerful inciter, the accessory muscles of 
parturition are brought into strong action, and there may be sufficient 
force to insure expulsion of the head without artificial aid. On account 
of the great resistance to the descent of the occiput from its articula- 
tion with the spinal column, the pains have the effect of forcing down 
the anterior portion of the head, and this insures the complete flexion 
of the chin upon the sternum (Fig. 115). This is a great advantage 
from a mechanical point of view, as it causes the short occipito-frontal 
diameter of the head to enter the pelvis in the axis of the uterus and 
the brim. If the head should be in a state of partial extension — as 
sometimes happens when the pelvis is unusually roomy — the occipito- 
mental diameter is placed in a similar relation to the brim, a position 
certainly less favorable to the easy birth of the head. As the head 
descends it experiences a movement of rotation, the occiput passing 
forward and to the right, behind the pubic arch, the face turning 
backward into the hollow of the sacrum. The body of the child will 
be observed to follow this movement, so that its back is turned toward 
the mother's abdomen, its anterior surface to the perineum. The nape 
of the neck now becomes firmly fixed under the arch of the pubes, the 
pains act chiefly on the anterior portion of the head, and cause it to 
sweep over the perineum, the chin being first born, then the mouth 
and forehead, and lastly the occiput. 

Fig. 115. 




Descent of the head. 

It is needless to describe the differences between the mechanism of 
the second (s.d.a.) and first (s.l.a.) positions, which the student who 
has mastered the subject of vertex presentations will readily under- 
stand. It is necessary, however, to say a few words as to sacro- 
posterior positions, choosing for that purpose the third (s.d.p.), which 

21 



322 LABOR. 

is the more common of the two. (Fig. 11-L) This is exactly the 
opposite of the first (S.L.A.) position. The sacrum of the child points 
to the right sacro-iliac synchondrosis, its abdomen looks forward and 
to the left side of the mother. The transverse diameter of the child's 
pelvis lies in the left oblique diameter, the right hip being anterior. 
The birth of the body generally takes place exactly in the way that has 
been already described, the right hip being toward the pubes. 

As the head descends into the pelvis the occiput most usually rotates 
along its right side — the rotation having been often already partially 
effected when that of the hips had been made — until it comes to rest 
behind the pubes, the face passing backward along the left side of the 
pelvis into the hollow of the sacrum. This change corresponds exactly 
to the anterior rotation of the occiput in occipito-posterior positions^ 
and is the natural and favorable termination. 

Sometimes, further rotation does not take place, and the occiput 
then turns backward into the hollow of the sacrum. What then 
generally occurs is, that the pains continue, for the reason already 
mentioned, to depress the chin and produce strong flexion of the face 
on the sternum, the occiput becoming fixed on the anterior border of 
the perineum. The pains continuing to act chiefly on the anterior 
part of the head, the face is born first behind the pubes, the occiput 
only slipping over the perineum after the forehead has been ex- 
pelled. 

The second mode of termination of such positions is mentioned in 
most works, on the authority of one or two recorded cases ; but 
although mechanically possible, it is certainly an event of extreme 
rarity. The chin, instead of being flexed on the sternum, is greatly 
extended, so that the face of the child looks upward toward the pelvic 
brim. The chin then hitches over the upper edge of the pubes and 
becomes fixed there, while the force of the uterine contractions is ex- 
pended on the posterior part of the head, which descends through the 
pelvis, distending the perineum, and is born first, the face subsequently 
following. 

The mechanism of the delivery of the body and head in cases in 
which the feet originally present does not differ, in any important 
respect, from that which has been already described, and requires no 
separate notice. 

Treatment. — From what has been said of the natural mechanism, 
it is evident that one of the most fruitful causes of difficulty and com- 
plication is undue interference on the part of the practitioner. It is, 
no doubt, tempting to use traction on the partially born trunk in the 
hope of expediting delivery ; but when it is remembered that this is 
almost certain to produce extension of the arms above the head, and 
subsequently extension of the occiput on the spine, both of which 
seriously increase the difficulty of delivery, the necessity of leaving 
the case as much as possible to Nature will be apparent. 

Having once, therefore, determined the existence of a pelvic pres- 
entation, nothing more should be done until the birth of the breech. 
The membranes should be even more carefully prevented from prema- 
turely rupturing than in vertex presentations, since they serve to dilate 



PELVIC PRESENTATIONS. 323 

the genital passages better than does the presenting part. Hence they 
should be preserved intact, if possible, until they reach the floor of the 
pelvis, instead of being punctured as soon as the os is fully dilated. 
The breech when born should be received and supported in the palm 
of the hand. 

When the body is expelled as far as the umbilicus, the dangers to 
the child commence ; for now the cord is apt to be pressed between 
the body of the child and the pelvic walls. To obviate this risk as 
much as possible, a loop of the cord should be pulled down, and car- 
ried to that part of the pelvis where there is most room, which will 
generally be opposite one or the other sacro-iliac synchondrosis. As 
long as the cord is freely pulsating we may be satisfied that the life of 
the child is not gravely imperilled, although delay is fraught with 
danger from other sources which have been already indicated. In 
most cases the arms now slip out ; but it may happen, even without 
any fault on the part of the accoucheur, that they are extended above 
the head, and it is of great importance that we should be thoroughly 
acquainted with the best means of liberating them from their abnormal 
position. 

They mast, of course, never be drawn directly downward, or the 
almost certain result would be fracture of the fragile bones. We 
should endeavor to make the arm sweep over the lace and chest of 
the child, so that the natural movements of its joints should not be 
opposed. If the shoulders be within easy reach, the finger of the 
accoucheur should be slipped over that which is posterior — because 
there is likely to be more space for this manoeuvre toward the sacrum 
— and gently carried downward toward the elbow, which is drawn 
over the face, and then onward, so as to liberate the forearm. The 
same manoeuvre should then be applied to the opposite arm. It may 
be that the shoulders are not easily reached, and then they may be 
depressed by altering the position of the child's body. If this be 
carried well up to the mother's abdomen, the posterior shoulder will 
be brought lower down ; and, by reversing this procedure and carry- 
ing the body back over the perineum, the anterior shoulder may be 
similarly depressed. It is only very exceptionally, however, that these 
expedients are required,, 

Birth of the Head. — The arms being extracted, some degree of 
artificial assistance is, at this time, almost always required. It' there 
be much delay, the child will almost certainly perish. Attempts have 
been made, in cases in which delivery of the head could not be rapidly 
effected, to establish pulmonary respiration by passing oue or two 
fingers into the vagina, so as to press it back and admit air to the 
child's mouth, or by passing a catheter or tube into the mouth. Neither 
of these expedients is reliable, and we should rather seek to aid Nature 
in completing the birth of the head as rapidly as possible. The first 
thing to do, supposing the face to have rotated into the cavity of the 
sacrum, is to carry the body of the child well up toward the pubes 
and abdomen of the mother without applying any traction for fear of 
interfering with the all-important flexion of the chin on the sternum. 

If now the patient bear down strongly, the natural powers may be 



324 LABOR. 

sufficient to complete delivery. If there be any delay, traction must 
be resorted to, and we must endeavor to apply it in such a way as to 
insure flexion. For this purpose, while the body of the child is 
grasped by the left hand, and drawn upward toward the mother's 
abdomen, the index and middle fingers of the right hand are placed 
on the back of the child's neck, so that their tips press on either side 
of the base of the occiput, and push the head into a state of flexion. 
In most works we are advised to pass the index and middle fingers of 
the left hand at the same time over the child's face, so as to depress 
the superior maxilla. Dr. Barnes insists that this is quite unnecessary, 
and that extraction in the manner indicated, by pressure on the occiput, 
is quite sufficient. Should it not prove so, flexion of the chin may be 
very effectually assisted by downward pressure on the forehead through 
the rectum. One or two fingers of the left hand can readily be inserted 
into the bowel, and the expulsion of the head is thus materially 
facilitated. 

By far the most powerful aid, however, in hastening delivery of the 
head, should delay occur, is pressure from above. This has been, 
strangely enough, almost altogether omitted by writers on the subject. 
It has been strongly recommended by Professor Penrose, and there 
can be no question of its utility. Indeed, as the uterus contracts 
tightly around the head, uterine expression can be applied almost 
directly to the head itself, and without any fear of deranging its 
proper relation to the maternal passages. It is very seldom indeed 
that a judicious combination of traction on the part of the accoucheur, 
with firm pressure through the abdomen applied by an assistant, will 
fail in effecting delivery of the head before the delay has had time to 
prove injurious to the child. 

Application of the Forceps to the After-coming' Head. — Many 
accoucheurs — among others, Meigs and Rigby — advocate the applica- 
tion of the forceps when there is delay in the birth of the after-coming 
head. If the delay be due to want of expulsive force in a pelvis of 
normal size, manual extraction, in the manner just described, will be 
found to be sufficient in almost every case, and preferable, as being 
more rapid, easier of execution, and safer to the child. The forceps 
may be quite properly tried, if other means have failed ; especially if 
there be some disproportion between the size of the head and the 
pelvis. 

Difficulties in delivery may also occur in sacro-posterior positions. 
Up to the time of the birth of the head the labor usually progresses as 
readily as in the sacro-anterior positions. If the forward rotation of 
the hips do not take place, much subsequent difficulty may be pre- 
vented by gently favoring it by traction applied to the breech during 
the pains, the finger being passed for this purpose into the fold of the 
groin. 

It is after the birth of the shoulders that the absence of rotation is 
most likely to prove troublesome. It has been recommended that the 
body should then be grasped, in the interval between the pains, and 
twisted around so as to bring the occiput forward. It is by no means 
certain, however, that the head would follow the movement imparted 



PELVIC PRESENTATIONS. 325 

to the body, and there must be a serious danger of giving a fatal twist 
of the neck by such a manoeuvre. The better plan is to direct the 
face backward, toward the cavity of the sacrum, by pressing on the 
anterior temple during the continuance of a pain. In this way the 
proper rotation will generally be effected without much difficulty, and 
the case will terminate in the usual way. 

If rotation of the occiput forward do not occur, it is necessary for 
the practitioner to bear in miud the natural mechanism of delivery 
under such circumstances. In the majority of cases the proper plan is 
to favor flexion of the chin by upward pressure on the occiput, and to 
exert traction directly backward, remembering that the nape of the 
neck should be fixed against the anterior margin of the perineum. If 
this be not remembered, and traction be made in the axis of the pelvic 
outlet, the delivery of the head will be seriously impeded. In the rare 
cases in which the head becomes extended, and the chin hitches on the 
upper margin of the pubes, traction directly forward and upward may 
be required to deliver the head ; but before resorting to it care should be 
taken to ascertain that backward extension of the head has really 
taken place. 

It remains for us to consider the measures which may be adopted in 
those troublesome cases in which the breech refuses to descend, and 
becomes impacted in the pelvic cavity, either from uterine inertia, or 
from disproportion between the breech and the pelvis. The peculiar 
shape of the presenting part unfortunately renders such cases very 
difficult to manage. 

Three measures have been chiefly employed : 1st, the forceps ; 
2d, bringing down one or both feet, so as to break up the presenting 
part, and convert it into a footling case j 3d, traction on the breech, 
either by the fingers, a blunt hook, or fillet passed over the groin. 

Forceps. — The forceps has generally been considered unsuited for 
breech cases in consequence of its construction to fit the foetal head, 
which renders it liable to slip when applied to the breech. The objec- 
tion, probably to a great extent true with reference to most forceps, 
seems not to hold good when the axis-traction forceps of Tarnier or 
Simpson is used. Lusk strongly recommends it, and Harvey, of 
Calcutta, has published six consecutive cases in which he employed 
this method of delivery, in three with complete success. Truzzi, 1 who 
has written strongly in favor of the forceps in difficult breech cases, 
prefers it greatly to traction either by the fingers or the fillet when the 
breech is high in the pelvis, and recommends that, in order to secure 
a strong hold, the blades should be passed so that their extremities 
extend above the crests of the foetal ilia. I have used it myself in 
several cases, but in these the results were extremely good, delivery 
was effected with a facility which surprised me, and I can see no ob- 
jection to a cautious trial of the instrument. 

Bringing- Dov/n a Foot. — Barnes insists on the superiority of the 
second plan, and there can be no question that, if a foot cau be got 
down, the accoucheur has a complete control over the progress of the 

' Gaz. Med. Ital. Lomb., August, 1883. 



326 LABOR. 

" labor which he can gain in no other way. If the breech be arrestd at 
or near the brim, there will generally be no great difficulty in effecting 
the desired object. It will be necessary to give chloroform to the 
extent of complete anaesthesia, and to pass the hand over the child's 
abdomen in the same manner, and with the same precautions, as in 
performing podalic version, until a foot is reached, which is seized 
and pulled down. If the feet be placed in the usual way close to the 
buttocks, no great difficulty is likely to be experienced. If, however, 
the legs be extended on the abdomen, it will be necessary to introduce 
the hand and arm very deeply, even u x to the fundus of the uterus, a 
procedure which is always difficult, and which may be very hazardous. 
Nor do I think that the attempt to bring down the feet can be safe 
when the breech is low down and fixed in the pelvic cavity. A cer- 
tain amount of repression of the breech is possible, but it is evident that 
this cannot be safely attempted when the breech is at all low down. 

Traction on the Groin. — Under such circumstances, if forceps is not 
used, traction is our only resource, aud this is always difficult and often 
unsatisfactory. Of all contrivances for this purpose none is better than 
the hand of the accoucheur. The index-finger can generally be slipped 
over the groin without difficulty, and traction can be applied during the 
pains. Failing this, or when it proves insufficient, an attempt should be 
made to pass a fillet over the groins. A soft silk handkerchief, or a 
skein of worsted, answers best, but it is by uo means easy to apply. The 
simplest plan, and one which is far better than the expensive instru- 
ments contrived for the purpose, is to take a stout piece of copper wire 
and bend it double into the form of a hook. The extremity of this can 
generally be guided over the hips, and through its looped end the 
fillet is passed. The wire is now withdrawn, and carries the fillet 
over the groins. I have found this simple contrivance, which can be 
manufactured in a few moments, very useful, and by means of such a 
fillet very considerable tractive force can be employed. The use of a 
soft fillet is in every way preferable to the blunt hook which is con- 
tained in most obstetric bags. A hard instrument of this kind is 
quite as difficult to apply, and any strong traction employed by it is 
almost certain to seriously injure the delicate foetal structures over 
which it is placed. As an auxiliary the employment of uterine 
expression should not be forgotten, since it may give material aid 
when the difficulty is only due to uterine inertia. 

Embryotomy. — Failing all endeavors to deliver by these expedients, 
there is no resource left but to break up the presenting part by scissors, 
or by craniotomy instruments ; but fortunately so extreme a measure 
is but rarely necessary. 

Examination of the Child. — After a difficult breech labor is com- 
pleted the child should be carefully examined to see that the bones of 
the thighs and arms have not been injured. Fractures of the thigh 
are far from uncommon in such cases, and the soft bones of the newly 
born child will readily and rapidly unite if placed at once in proper 
splints. 



PRESENTATIONS OF THE FACE. 327 



CHAPTEE VI. 

PRESENTATIONS OF THE FACE. 

Presentations of the face are by no means rare ; and, although in 
the great majority of eases they terminate satisfactorily by the un- 
assisted powers of Nature, yet every now and again they give rise to 
much difficulty, and then they may be justly said to be amongst the 
most formidable of obstetric complications. It is, therefore, essential 
that the practitioner should thoroughly understand the natural history 
of this variety of presentation, with the view of enabling him to 
intervene with the best prospect of success. 

The older accoucheurs had very erroneous views as to the mechanism 
and treatment of these cases, most of them believing that delivery was 
impossible by the natural efforts, and that it was necessary to inter- 
vene by version in order to effect delivery. Smellie recognized the 
fact that spontaneous delivery is" possible, and that the chin turns for- 
ward and under the pubes ; but it was not until long after his time, 
and chiefly after the appearance of Mine. La Chapelle's essay on the 
subject, that the fact that most cases could be naturally delivered was 
fully admitted and acted upon. 

Frequency. — The frequency of face presentations varies curiously 
in different countries. Thus, Collins found that in the Rotunda 
Hospital there was only 1 case in 497 labors, although Churchill gives 
1 in 249 as the average frequency in British practice ; while in 
Germany this presentation is met with once in 169 labors. The only 
reasonable explanation of this remarkable difference is, that the dorsal 
decubitus, generally followed abroad, favors the transformation of 
vertex presentations into those of the face. 

The mode in which this change is effected — for it can hardly be 
doubted that, in the large majority of cases, face presentation is due 
to a backward displacement of the occiput after labor has actually 
commenced, but before the head has engaged in the brim — has been 
made the subject of various explanations. 

It has generally been supposed that the change is induced by a 
hitching of the occiput on the brim of the pelvis, so as to produce 
extension of the head, and descent of the face ; the occurrence being 
favored by the oblique position of the uterus so frequently met with 
in pregnancy. Hecker 1 attaches considerable importance to a pecu- 
liarity in the shape of the fretal head generally observed in face pres- 
entations, the cranium having the dolicho-cephalous form, prominent 
posteriorly, with the occciput projecting, which has the effect of in- 
creasing the length of the posterior cranial lever arm, and facilitating 
extension when circumstances favoring it are in action. Dr. Duncan 2 

1 T'eber die Schadelform bei Gesichtslagen. 

2 Edin. Med. Journ., vol. xv. 



328 LABOR. 

thinks that uterine obliquity has much influence in the production of 
face presentation, but in a different way to that above referred to. He 
points out that, when obliquity is very marked, a curve in the genital 
passages is produced, the convexity of which is directed to the side 
toward which the uterus is deflected. When uterine contraction com- 
mences, the foetus is propelled downward, and the part corresponding 
to the concavity of the curve is acted on to the greatest advantage by 
the propelling force, and tends to descend. Should the occiput happen 
to lie in the convexity of the curve so formed, the tendency will be 
for the forehead to descend. In the majority of cases its descent will 
be prevented by the increased resistance it meets with, in consequence 
of the greater length of the anterior cranial lever arm ; but, if the 
uterine obliquity be extreme, this may be counterbalanced, and a face 
presentation ensues. The influence of this obliquity is corroborated 
by the observation of Baudelocque, that the occiput in face presenta- 
tions almost invariably corresponds to the side of the uterine obliquity. 
A further corroboration is afforded by the fact that in face presentation 
the occiput is much more frequently directed to the right than to the 
left ; while right lateral obliquity of the uterus is also much more 
common. 

These theories assume that face presentations are produced during 
labor. In a few cases they certainly exist before labor has commenced. 
It is possible, however, as we know that uterine contractions exist in- 
dependently of actual labor, that similar causes may also be in opera- 
tion, although less distinctly, before the commencement of labor. Other 
conditions, such as slight flattening of the pelvic brim, or the existence 
of a small fibroid in the lower segment of the uterus, probably also 
favor their production. 

The diagnosis is often a matter of considerable difficulty at an 
early period of labor, before the os is fully dilated and the membranes 
ruptured, and when the face has not entered the pelvic cavity. The 
finger then impinges on the rounded mass of the forehead, which may 
very readily be mistaken for the vertex. At this stage the diagnosis 
may be facilitated by abdominal palpation in the way suggested by 
Hecker. If the face is presenting at the brim, palpation will enable 
us to distinguish a hard, firm, and rounded body, immediately above 
the pubes, which is the forehead and sinciput ; on the other side will 
be felt an indistinct, soft substance, corresponding to the thorax and 
neck. When labor is advanced, and the head has somewhat descended, 
or when the membranes are ruptured, we should be able to make out 
the nature of the presentation with certainty. The diagnostic marks 
to be relied on are the edges of the orbits, the prominence of the nose, 
the nostrils (their orifices showing to which part of the pelvis the chin 
is turned), and the cavity of the mouth, with the alveolar ridges. If 
these be made out satisfactorily, no mistake should occur. The most 
difficult cases are those in which the face has been a considerable time 
in the pelvis. Under such circumstances the cheeks become greatly 
swollen and pressed together, so as to resemble the nates. The nose 
might then be mistaken for the genital organs, and the mouth for the 
anus. The orbits, however, and the alveolar ridges, resemble nothing 
in the breech, and should be sufficient to prevent error. 



PRESENTATIONS OF THE FACE. 329 

Considerable care should be taken not to examine too frequently 
and roughly, otherwise serious injury to the delicate structures of the 
face might be inflicted. It is also a matter of great importance to keep 
the membranes unruptured as long as possible in the hope of spon- 
taneous rectification, which may possibly occur, and also because com- 
plete dilatation of the os is of great importance for the satisfactory 
progress of the case. Therefore, when once the presentation has been 
satisfactorily diagnosed, examinations should be made as seldom as 
possible, and only to assure ourselves that the case is progressing satis- 
factorily. 

Mechanism. — If we regard face presentations, as we are fully justified 
in doing, as being generally produced by the extension of the occiput 
in what were originally vertex presentations, we can readily under- 
stand that the position of the face in relation to the pelvis must cor- 
respond to that of the vertex. This is, in fact, what is found to be 
the case, the forehead occupying the position in which the occiput 
would have been placed had extension not occurred. 

The face, then, like the head, may be placed with its long diameter 
corresponding to almost any of the diameters of the brim, but most 
generally it lies either in the transverse diameter, or between this and 
the oblique, while, as it descends in the pelvis, it more generally occu- 
pies one or other of the oblique diameters. It is common in obstetric 
works to describe two principal varieties of face presentation, viz., the 
right and left mento-iliac, according as the chin is turned to one or 
other side of the pelvis. It is better, however, to classify the positions 
in accordance with the part of the pelvis to which the chin points. 
We may, therefore, describe four positions of the face, each being 
analogous to one of the ordinary vertex presentations, of which it is 
the transformation. 

The Four Positions generally met with. — First position (mento- 
dextra posterior, m.d.p.). The chin points to the right sacro-iliac 
synchondrosis, the forehead to the left foramen ovale, and the long 
diameter of the face lies in the right oblique diameter of the pelvis. 
This corresponds to the first position of the vertex, and, as in that, the 
back of the child lies to the left side of the mother. 

Second position (rnento-lseva posterior, m.l.p.). The chin points to 
the left sacro-iliac synchondrosis, the forehead to the right foramen 
ovale, and the long diameter of the face lies in the left oblique 
diameter of the pelvis. This is the conversion of the second vertex 
position. 

Third position (mento-l?eva anterior, M.L.A.). The forehead (Fig. 
116) points to the right sacro-iliac synchondrosis, the chin to the left 
foramen ovale, and the long diameter of the face lies in the right 
oblique diameter of the pelvis. This is the conversion of the third 
vertex position. 

Fourth position (mento-dextra anterior, M.D.A.). The forehead points 
to the left sacro-iliac synchondrosis, the chin to the right foramen 
ovale, and the long diameter of the face lies in the left oblique 
diameter of the pelvis. This is the conversion of the fourth vertex 
position. 



330 LABOR. 

The relative frequency of these presentations is not yet positively 
ascertained. It is certain that there is not the preponderance of first 
facial (m.d.p.) that there is of first vertex (o.l.a.) positions, and this 
may, no doubt, be explained by the supposition that an unusual vertex 
position may of itself facilitate the transformation into a face pres- 
entation. Winckel concludes that, cceteris paribus, a face presentation 
is more readily produced when the back of the child lies to the right 
than when it lies to the left side of the mother ; the reason for this 
being probably the frequency of right lateral obliquity of the uterus. 
We shall presently see that, with very rare exceptions, it is absolutely 
essential that the chin should rotate forward under the pubes before 
delivery can be accomplished ; and, therefore, we may regard the third 
and fourth face positions, in which the chin from the first points ante- 
riorly, as more favorable than the first and second. 

The mechanism of delivery in face is practically the same as in 
vertex presentations ; and we shall have no difficulty in understand- 

FlG. 116. 




Third position (m.l.a.) in face presentations. 



ing it if we bear in mind that in face cases the chin takes the place of, 
and represents the occiput in, vertex presentations. For the purpose 
of description we will take the first position of the face. 

1. Extension. — The first step consists in the extension of the head, 
which is effected by the uterine contractions as soon as the membranes 
are ruptured. By this the occiput is still more completely pressed 
back on the nape of the neck, and the fronto-mental, rather than the 
mento-bregmatic, diameter is placed in relation to the pelvic brim. 
This corresponds to the stage of flexion in vertex presentations. 

The chin descends below the forehead, from precisely the same 
cause as the occiput in vertex presentations. On account of the ex- 



PRESENTATIONS OF THE FACE. 



331 



tended position of the head the presenting face is divided into portions of 
unequal length in relation to the vertebral column, through which the 
force is applied, the longer lever arm being toward the forehead. The 
resistance is, therefore, greatest toward the forehead, which remains 
behind while the chin descends. 

2. Descent. — As the pains continue, the head (the chin being still 
in advance) is propelled through the pelvis. It is generally said that 
the face cannot descend, like the occiput, down to the floor of the 
pelvis, its descent being limited by the length of the neck. There is 
here, however, an obvious misapprehension. The neck, from the chin 
to the sternum, when the head is forcibly extended, measures from 
three and a half to four inches, a length that is more than sufficient to 
admit of the face descending to the lower pelvic strait. As a matter 
of fact, the chin is frequently observed in mento-posterior positions to 
descend so far that it is apparently endeavoring to pass the perineum 
before rotation occurs. At the brim the two sides of the face are on a 
level, but as labor advances the right cheek descends somewhat, the 
caput succedaneum forms on the malar bone, and, if a secondary caput 
succedaneum form, on the cheek. 

3. Rotation is by far the most important point in the mechanism 
of face presentations ; for unless it occurs, delivery, with a full-sized 
head and an average pelvis, is practically impossible. There are, no 
doubt, exceptions to this rule, which must be separately considered, 

Fig. 117. 




Rotation forward of chin. 



but it is certain that the absence of rotation is always a grave and for- 
midable complication of face presentation. Fortunately it is only 
very rarely that this is not effected. The mechanical causes are pre- 
cisely those which produce rotation of the occiput forward in vertex 



332 



LABOR 



presentations. As it is accomplished, the chin passes under the arch 
of the pubes, and the occiput rotates into the hollow of the sacrum 
(Fig. 117) ; and then commences — 

4. Flexion, a movement which corresponds to extension in vertex 
cases. The chin passes as far as it can under the pubic arch, and there 

Fig. 118. 




Passage of the head through the external parts in face presentation. 
Fig. 119. 




Illustrating the position of the head when forward rotation of the chin does not take place. 

becomes fixed. The uterine force is now expended on the occiput, 
which revolves, as it were, on its transverse axis (Fig. 118), the under 
surface of the chin resting on the pubes as a fixed point. This move- 
ment goes on until, at last, the face and occiput sweep over the 
distended perineum. 



PRESENTATIONS OF THE FACE. 333 

5. External rotation is precisely similar to that which takes place 
in head presentations, and, like it, depends ou the movements imparted 
to the shoulders. 

Such is the natural course of delivery in the vast majority of cases; 
but, in order fully to understand the subject, it is necessary to study 
those rare cases in which the chin points backward, and forward rota- 
tion does not occur. These may be taken to correspond to the 
occipito-posterior positions, in which the face is born looking to the 
pubes ; but, unlike them, it is only very exceptionally that delivery 
can be naturally completed. The reason of this is obvious, for the 
occiput gets jammed behind the pubes, and there is no space for the 
fronto-mental diameter to pass the antero-posterior diameter of the out- 
let (Fig. 119). Cases are indeed recorded in which delivery has been 
effected with the chin looking posteriorly ; but there is every reason 
to believe that this can only happen when the head is either unusually 
small, or the pelvis unusually large. In such cases the forehead is 
pressed down until a portion appears at the ostium vaginae, when it 
becomes firmly fixed behind the pubes, and the chin, after many 
efforts, slips over the perineum. When this is effected, flexion occurs, 
and the occiput is expelled without difficulty. The forehead is 
probably always on a lower level than the chin. 

Dr. Hicks 1 has published a paper in which he attempts to show 
that this termination of face presentations is not so rare as is generally 
supposed, and he gives a single instance in which he effected delivery 
with the forceps ; but he practically admits that special conditions are 
necessary, such as the " antero-posterior diameter of the outlet particu- 
larly ample/' and a diminished size of the head. When delivery is 
effected it is probable, as Cazeaux has pointed out, that the face lies in 
the oblique diameter of the outlet, and that the chin depresses the soft 
structures at the side of the sacro-ischiatic notch, which yield to the 
extent of a quarter of an inch or more, and thereby permit the passage 
of the occipito-mental diameter of the head. It must, however, be 
borne well in mind, that spontaneous delivery in mento-posterior 
positions is the rare exception, and that, supposing rotation does not 
occur — and it often does so at the last moment — artificial aid in one 
form or another will be almost certainly required. 

Prognosis of Face Presentations. — As regards the mother, in the 
great majority of cases the prognosis is favorable, but the labor is apt 
to be prolonged, and she is, therefore, more exposed to the risks 
attending tedious delivery. As regards the child, the prognosis is 
much more unfavorable than in vertex presentations. Even when the 
anterior rotation of the chin takes place in the natural way, it is 
estimated that one out of ten children is stillborn ; while, if not, the 
death of the child is almost certain. This increased infantile mortality 
is evidently due to the serious amount of pressure; to which the child 
is subjected, and probably depends in many cases on cerebral conges- 
tion, produced by pressure on the jugular veins, as the neck lies in the 
pelvic cavity. Even when the child is born alive, the face is always 

' Obstet. Trans., vol vii. p. 67. 



834 LABOR. 

greatly swollen and disfigured. In some cases the deformity produced 
in this way is excessive, and the features are often scarcely recog- 
nizable. This disfiguration passes away in a few days ; but the prac- 
titioner should be aware of the probability of its occurrence, and 
should warn the friends, or they might be unnecessarily alarmed, and 
possibly might lay the blame on him. 

Treatment. — After what has been said as to the mechanism of 
delivery in face presentation, it is obvious that the proper course is to 
leave the case alone, in the expectation of the natural efforts being 
sufficient for complete delivery, providing the chin is pointing ante- 
riorly. Fortunately, in the large majority of such cases, especially in 
multipara^ this course is attended by a successful result. 

The older accoucheurs, as has been stated, thought active interference 
absolutely essential, and recommended either podalic version, or the 
attempt to convert the case into a vertex presentation, by inserting the 
hand and bringing down the occiput. The latter plan was recom- 
mended by Baudelocque, and is even yet followed by some accoucheurs. 
Thus Dr. Hodge 1 advises it in all cases in which face presentation is 
detected at the brim; but although it might not have been attended 
with evil consequences in his experienced hands, it is certainly altogether 
unnecessary, and would infallibly lead to most serious results if gener- 
ally adopted. It may, however, be allowable in certaiu cases iu which 
the face remains above the brim, and refuses to descend into the pelvic 
cavitv, especially if the membranes have ruptured early and the os is 
insufficiently dilated, for then the child will necessarily be subjected to 
great risk from the pressure of the undilated cervix on the vessels of 
the neck. The aseptic hand may then be introduced and the head dis- 
engaged, the chin being pushed up so as to restore flexion. As scon as 
this is done the head should be pushed into the brim by pressure on 
the fundus, so as to make it engage in the brim in what will then be 
an occipito-posterior position. Even then it is questionable whether 
podalic version should not be preferred, as being easier of performance, 
giving, when once effected, a much more complete control over delivery. 
Version is certainly preferable to the application of the forceps, which 
are introduced with difficulty in so high a position of the face, and do 
not take a secure hold, provided the face has not emerged from the mouth 
of the uterus. If the face has passed through the cervix, version could 
not be effected without serious risk of rupture of the uterus. 

Schatz 2 has suggested the rectification of face presentations at an early 
stage, before the rupture of the membranes, by manipulation through 
the abdomen. He raises the foetal body by pressure on the shoulder 
and breast through the abdominal wall by one hand, while the breech 
is raised and steadied by the other. By this means the occiput is ele- 
vated, and then the breech is pressed downward, when head flexion is 
produced by the resistance of the pelvic walls. Of this method I have 
had no practical experience, but it obviously requires an unusual 
amount of skill and practice in abdominal palpation. 

Treatment of Mento-posterior Positions. — When mento-posterior 

* System of Obstetrics, p. 334. -' Arch, i. Gyn., Bd. v. S. 313. 



PRESENTATION OF THE FACE. 335 

positions are detected early in labor, before the face has descended into 
the pelvic cavity, either reposition or version should certainly be per- 
formed. The difficulties likely to arise in such cases are so great that 
their avoidance by early interference is not only justifiable but advis- 
able. In these cases reposition, if it can be accomplished, has the ad- 
vantage of converting the presentation into an ordinary occipito-anterior 
position. If the os is only partially dilated, bi-polar version may be 
attempted in the first instance. 

When once the face has descended into the pelvis, difficulties may 
arise from two chief causes : uterine inertia, and non-rotation forward 
of the chin. 

The treatment of the former class must be based on precisely the 
same general principles as in dealing with protracted labor in vertex 
presentations. The forceps may be applied Avith advantage, bearing 
in mind the necessity of getting the chin under the pubes, and, when 
this has been effected, of directing the traction forward, so as to make 
the occiput slowly and gradually distend and sweep over the perineum. 

The second class of difficult face cases is much more important, 
and may try the resources of the accoucheur to the utmost. Our first 
endeavor must be, if possible, to secure the anterior rotation of the 
chin. For this purpose various manoeuvres are recommended. By 
some, we are advised to introduce the finger cautiously into the mouth 
of the child, and draw the chin forward during a pain ; by others, to 
pass the finger up behind the occiput and press it backward during the 
pain. Schroeder points out that the difficulty often depends on the 
fact of the head not being sufficiently extended, so that the chin is not 
on a lower level than the forehead ; and that rotation is best promoted 
by pressing the forehead upward with the finger during a pain, so as 
to cause the chin to descend. Penrose l believes that non-rotation is 
generally caused by the want of a point oVappui below, on account of 
the face being unable to descend to the floor of the pelvis, and that, if 
this is supplied, rotation will take place. In such cases he applies the 
hand, or the blade of the forceps, so as to press on the posterior cheek. 
By this means the necessary point oVappui is given ; and he relates 
several interesting cases in which this simple manoeuvre was effectual 
in rapidly terminating a previously lengthy labor. Any, or all, of 
these plans may be tried. AVe must bear in mind, in using them, that 
rotation is often delayed until the face is quite at the lower pelvic strait, 
so that we need not too soon despair of its occurring. If, however, in 
spite of these manoeuvres, it does not take place, what is to be done? 
An attempt might be made to bring down the occiput by the vectis, or 
by a fillet ; but if the face be in the pelvic cavity, it is hardly possible 
for this plan to succeed. An endeavor may be made to produce rota- 
tion by the forceps; but it should be remembered that rotation of the 
face mechanically in this way is very difficult, and much more likely 
to be attended with fatal consequences to the child than when it is 
effected by the natural efforts. In using forceps for this purpose, the 
second or pelvic curve is likely to prove injurious, and a short straight 

i Amer. Supplement to Obst. Journ., vol. iv. p. i. 



336 



LABOR, 



Fig. 120. 



instrument is to be preferred. If rotation is found to be impossible, 
an endeavor may be made to draw the face downward, so as to get the 
chin over the perineum, and deliver in the men to posterior position ; 
but uuless the child be small, or the pelvis very capacious, the attempt 
is unlikely to succeed. Finally, if all these means fail, the only possi- 
ble resources are either symphysiotomy or craniotomy. The former 
has not been practised sufficiently often in such cases to justify an esti- 
mate of its success. Lusk performed it once, but under very unfavor- 
able conditions when the patient was practically moribund, but after it 
he found reposition quite easy, and the child was delivered by the 
forceps. If auscultation showed that the child was alive, I should 
myself certainly attempt it. Either operation is certainly preferable 
to long-continued and violent endeavors to deliver with the chin point- 
ing backward. 

Brow Presentations. — It sometimes happens that the head is par- 
tially extended, so as to bring the os frontis into the brim of the pelvis, 
and form what is described as a brow presentation. Should the head 
descend in this manner, the difficulties, although not insuperable, are 
apt to be very great, from the fact that the long cervico-frontal diam- 
eter of the head is engaged in the pelvic cavity. The diagnosis is not 

difficult, for the os frontis will be detected 
by its rounded surface, while the anterior 
fontanelle is within reach in one direc- 
tion, the orbit and root of the nose in 
another. 

Fortunately, in the large majority of 
cases, brow presentations are spontane- 
ously converted into either vertex or face 
presentations, according as flexion or ex- 
tension of the head occurs ; and these 
must be regarded as the desirable termi- 
nations and the ones to be favored. For 
this purpose upward pressure must be 
made on one or other extremity of the 
presenting part during a pain, so as to 
favor flexion or extension ; or, if the 
parts be sufficiently dilated, an attempt 
may be made to pass the hand over the occiput and draw it down, thus 
performing cephalic version. The latter is the plan recommended by 
Hodge, who describes the operation as easy. Long, in an excellent 
paper on this subject, has given figures to show that correction of the 
malpresentation by manipulation has given better results than any 
other method of treatment. 1 It is questionable, however, if a well- 
marked brow presentation be distinctly made out while the head is 
still at the brim, whether podalic version would not be the easiest and 
best operation. If the forehead has descended too low for this, and 
if the endeavor to convert it into either a face or vertex presentation 
fails, the forceps wdll probably be required. In such cases the face 




Brow presentation, subsequently 
converted into that of the face. 
(After Lusk.) 



1 American Journal of Obstetrics, vol. xviii. p. 897. 



DIFFICULT 0CCIP1T0-P0STERI0R POSITIONS. 337 

generally tarns toward the pubes, the superior maxilla becomes fixed 
behind the pubic arch, and the occiput sweeps over the perineum. 
Very great difficulty is likely to be experienced, and, if conversion 
into either a vertex or face presentation cannot be effected, we must 
consider either the performance of symphysiotomy or craniotomy is not 
unlikely to be required. After birth the head will be unusually dis- 
figured from the pressure to which it has been subjected, the swelling 
mainly forming over the forehead, between the root of the nose and 
the anterior angle of the greater fontanelle (Fig. 120). 



CHAPTEE VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

A few words may be said in this place as to the management of 
occipito-posterior positions of the head, especially of those in which 
forward rotation of the occiput does not take place. It has already 
been pointed out that, in the large majority of these cases, the occiput 
rotates forward without any particular difficulty, and the labor termi- 
nates in the usual way with the occiput emerging under the arch of 
the pubes. 

In a certain number of cases such rotation does not occur, and diffi- 
culty and delay are apt to follow. The proportion of cases in which 
face-to-pubes terminations of occipito-posterior positions occur has 
been variously estimated, and they are certainly more common than 
most of our text-books lead us to expect. Dr. Uvedale West, 1 who 
studied the subject with great care, found that labor ended in this 
way in 79 out of 2585 births, all these deliveries being exceptionally 
difficult. 

Causes of Face-to-Pubes Delivery. — He believed that forward 
rotation of the head is prevented by the absence of flexion of the chin 
on the sternum, so that the long occipito-frontal (o.f.), instead of the 
short sub-occipito-bregmatic (s.o.B.), diameter of the head is brought 
into contact with the pelvic diameter ; hence the occiput is no longer 
the lowest point, and is not subjected to the action of those causes 
which produce forward rotation. Dr. Maedonald, who has written a 
thoughtful paper on the subject, 2 believes that the non-rotation forward 
of the occiput is chiefly due to the large size of the head, in conse- 
quence of which "the forehead gets so wedged into the pelvis anteriorly 
that its tendency to slacken and rotate backward does not come into 
play." Dr. West's explanation, which lias an important bearing on 
the management of these cases, seems to explain most correctly the 
non-occurrence of the natural rotation. 

i Cranial Presentations, p. 33. - Bdin. Med. Journ., vol. x.\ p. 302. 

22 



338 LABOR. 

The important question for us to decide is, How can we best assist 
in the management of cases of this kind when difficulties arise, and 
labor is seriously retarded ? 

Mode of Treatment of Such Oases. — Dr. West, insisting strongly 
on the necessity of complete flexion of the chin on the sternum, advises 
that this should be favored by upward pressure on the frontal bone, 
with the view of causing the chin to approach the sternum, and the 
occiput to descend, and thus to come within the action of the agencies 
which favor rotation. Supposing the pains to be strong, and the 
fontanelle to be readily within reach, we may, in this way, very pos- 
sibly favor the descent of the occiput, and without injuring the 
mother, or increasing the difficulties of the case in the event of the 
manoeuvre failing. The beneficial effects of this simple expedient are 
sometimes very remarkable. In two cases in which I recently adopted 
it, labor, previously delayed for a length of time without any apparent 
progress, although the pains were strong and effective, was in each 
instance rapidly finished almost immediately after the upward press- 
ure was applied. The rotation of the face backward may at the same 
time be favored by pressure on the pubic side of the forehead during 
the pains. 

Others have advised that the descent of the occiput should be pro- 
moted by downward traction, applied by the vectis or fillet. The 
latter is the plan specially advocated by Hodge ; 1 and the fillet cer- 
tainly finds one of its most useful applications in cases of this kind, 
as being simpler of application and probably more effective than the 
vectis. 

Although any of these methods may be adopted, a word of caution 
is necessary against prolonged and over-active endeavors at producing 
flexion and rotation when that seems delayed. All who have watched 
such cases must have observed that rotation often occurs spontaneously 
at a very advanced period of labor, long after the head has been 
pressed down for a considerable time to the very outlet of the pelvis, 
and when it seems to have been making fruitless endeavors to emerge ; 
so that a little patience will often be sufficient to overcome the diffi- 
culty. 

Bataillard 2 advises the introduction of the antisepticized hand when 
rotation does not occur, with which the head is dislodged from the 
sacrum, and gently rotated forward. He relates many instances in 
which this manoeuvre was successful. A similar procedure was practised 
by Smeilie, and has been recently advocated by Fry, who speaks 
favorably of it. 3 Should it fail, and further assistance be required, 
there is no reason why the forceps should not be used. The in- 
strument is not more difficult to apply than under ordinary cir- 
cumstances, nor, as a rule, is much more traction necessary. Dr. 
Macdonald, indeed, in the paper already alluded to, maintains that 
in persistent occipito-posterior positions there is almost always a want 
of proportion between the head and the pelvis, and that, therefore, the 
forces will be generally required, and he prefers them to any artificial 

i System of Obstetrics, p. 308. 2 Ann. de Gyn., August, 1889. 

3 " Manual Rectification of Faulty Head Position." Amer. Journ. Obstet., March, 1897. 



DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 339 

attempts at rectification. Some peculiarities iu the mode of delivery 
are necessary to bear in mind. In most works it is taught that the 
operator should pay special attention to the rotation of the head, and 
should endeavor to impart this movement by turning the occiput for- 
ward during extraction. Thus Tyler Smith says : " In delivery with 
the forceps in occipito-posterior presentations, the head should be 
slowly rotated during the process of extraction so as to bring the 
vertex toward the pubic arch, and thus convert them into occipito- 
anterior presentations." The danger accompanying any forcible 
attempt at artificial rotation will, however, be evident on slight con- 
sideration. It is true that in many cases, when simple traction is 
applied, the occiput will, of itself, rotate forward, carrying the instru- 
ment with it. But that is a very different thing from forcibly twisting 
the head around with the blades of the forceps, without any assurance 
that the body of the child will follow the movement. It is impossible 
to conceive that such violent interference would not be attended with 
serious risk of injury to the neck of the child. If rotation do not 
occur, the fair inference is that the head is so placed as to render 
delivery with the face to the pubes the best termination, and no 
endeavor should be made to prevent it. This rule of leaving the 
rotation entirely to Xature, and using traction only, has received the 
approval of Barnes and most modern authorities, and is the one which 
recommends itself as the most scientific and reasonable. 

These are cases in which the pelvic curve of the forceps is of 
doubtful utility. When applied in the usual way the convexity of 
the blades points backward. If rotation accompany extraction, the 
blades necessarily follow the movement of the head, and their convex 
edges will turn forward. It certainly seems probable that such a 
movement would subject the maternal soft parts to considerable risk. 
I have, however, more than once seen such rotation of the instrument 
happen without any apparent bad result ; but the dangers are obvious. 
Hence it would be a wise precaution, either to use a pair of straight 
forceps for this particular operation, or to remove the blades and leave 
the case to be terminated by the natural powers, when the head is at 
the lower strait, and rotation seems about to occur. Prof. Richardson 1 
advises that when forceps are applied in persistent occipito-posterior 
positions, they should be introduced with the pelvic curve reversed. 
He claims for this method that the traction is chiefly exerted on the 
occiput, where it is most needed, which thereby descends and produces 
the necessary flexion of the chin on the sternum. The forceps are 
then removed, and, if the pains are sufficient, rotation forward is sure 
to take place. Of this plan I have no personal experience. When 
there is no rotation, more than usual care should be taken with the 
perineum, which is necessarily much stretched by the rounded occiput. 
Indeed, the risk to the perineum is very considerable, and, even with 
the greatest care, it may be impossible to avoid laceration. 

Bearing these precautions in mind, delivery with the forceps in 
occipito-posterior positions offers no special difficulties or dangers. 

1 Medical Communication to the Massachusetts Medical Society, vol. xiii. No. 4. 



340 LABOR 



CHAPTER VIII. 

PRESENTATIONS OF THE SHOULDER, ARM, OR TRUNK.— 
COMPLEX PRESENTATIONS.— PROLAPSE OF THE FUNIS. 

In the presentations already considered the long diameter of the 
foetus corresponded with that of the uterine cavity, and in all of them 
the birth of the child by the maternal efforts was the general and 
normal termination of labor. We have now to discuss those important 
cases in which the long diameter of the foetus and uterus do not cor- 
respond, but in which the long foetal diameter lies obliquely across the 
uterine cavity. In the large majority of these it is either the shoulder 
or some part of the upper extremity that presents ; for it is an admitted 
fact that, although other parts of the body, such as the back or ab- 
domen, may, in exceptional cases, lie over the os at an early period of 
labor, yet, as labor progresses, such presentations are almost always 
converted into those of the upper extremity. 

For all practical purposes we may confine ourselves to a considera- 
tion of shoulder presentations ; the further subdivision of these into 
elbow or hand presentations being no more necessary than the division 
of pelvic presentations into breech, knee, and footling cases, since the 
mechanism and management are identical, whatever part of the upper 
extremity presents. 

There is this great distinction between the presentations we are now 
considering and those already treated of, that, on account of the rela- 
tions of the foetus to the pelvis, delivery by the natural powers is 
impossible, except under special and very unusual circumstances that 
can never be relied upon. Intervention on the part of the accoucheur 
is, therefore, absolutely essential, and the safety of both the mother 
and child depends upon the early detection of the abnormal position 
of the foetus ; for the necessary treatment, which is comparatively easy 
and safe before labor has been long in progress, becomes most difficult 
and hazardous if there have been much delay. 

Position of the Foetus. — Presentations of the upper extremity or 
trunk are often spoken of as transverse presentations or cross-births ; 
but both of these terms are misleading, as they imply that the foetus 
is placed transversely in the uterine cavity, or that it lies directly 
across the pelvic brim. As a matter of fact, this is never the case, for 
the child lies obliquely in the uterus, not indeed in its long axis, but 
in one intermediate between its long and transverse diameters. 

Two great divisions of shoulder presentations are recognized : the 
one in which the back of the child looks to the abdomen of the mother 
(Fig. 121), and the other in which the back of the child is turned 
toward the spine of the mother (Fig. 122). Each of these is sub- 



PRESENTATIONS OF SHOULDER, ETC 



341 



divided into two subsidiary classes, according as the head of the child 
is placed in the right or left iliac fossa. Thus in dorso-anterior posi- 
tions, if the head lie in the left iliac fossa (left scapula anterior — scapula- 
Iseva anterior, s.l. a.), the right shoulder of the child presents; if in 



Fig. 121. 




Dorso-anterior presentation of the arm (s.l.a.). 
Fig. 122. 




Dorso- posterior presentation of the arm (s.d.p.), 



the right iliac fossa (right scapula anterior — «capula-dextra anterior, 
s.d.a.), the left. So in dorso-posterior positions, if the head lie in the 
left iliac fossa (left scapula posterior — seapula-laeva posterior, s.l. p.), the 
left shoulder presents; if in the right, the right (right scapula posterior — 



342 LABOR. 

scapula-dextra posterior, s.d. p.). 1 Of the two classes the dorso anterior 
positions are more common — in the proportion, it is said, of two to one. 
The causes of shoulder presentation are not well known. Amongst 
those most commonly mentioned are prematurity of the foetus, and 
excess of liquor amnii ; either of these, by increasing the mobility of 
the foetus in utero, would probably have considerable influence. The 
fact that it occurs much more frequently amongst premature births has 
long been recognized. Slight contraction of the pelvic brim, which 
renders the engagement of the head difficult, is certainly a predis- 
posing cause. Undue obliquity of the uterus has probably some 
influence, since the early pains may cause the presenting part to 
hitch against the pelvic brim, and the shoulders to descend. An 
unusually low attachment of the placenta to the inferior segment of the 
uterine cavity has been mentioned as a predisposing cause. In conse- 
quence of this the head does not lie so readily in the lower uterine 
segment, and is apt to slip up into one of the iliac fossae. This is sup- 
posed to explain the frequency of arm presentation in cases of partial 
or complete placenta prsevia. Danyau and Wigand believe that 
shoulder presentations are favored by irregularity in the shape of the 
uterine cavity, especially a relative increase in its transverse diameter. 
This theory has been generally discredited by writers, and it is cer- 
tainly not susceptible of proof; but it seems far from unlikely that 
some peculiarity of shape may exist, not capable of recognition, but 
sufficient to influence the position of the foetus. How otherwise are 
we to explain those remarkable cases, many of which are recorded, in 
which similar malpositions occurred in many successive labors ? Thus 
Joulin refers to a patient who had an arm presentation in three suc- 
cessive pregnancies, and to another who had shoulder presentation in 
three out of four labors, while Eustache, of Lille, 2 describes the case 
of a patient who had thirteen shoulder presentations out of fourteen 
deliveries. Certainly, such constant recurrences of the same abnor- 
mality could only be explained on the hypothesis of some very per- 
sistent cause such as that referred to. Pinard 3 states that shoulder 
presentations are seven times more common in multipara? than in pri- 
miparse, in consequence, as he believes, of the laxity of the abdominal 
walls in the former, which allows the uterus to fall forward, and thus 
prevents the head entering the pelvic brim in the latter weeks of preg- 
nancy. It is probable that merely accidental causes have most influ- 
ence in the production of shoulder presentation, such as falls, or undue 
pressure exerted on the abdomen by badly fitting or tight stays. Par- 
tially transverse positions during pregnancy are certainly much more 
common than is generally believed, and may often be detected by 
abdominal palpation. The tendency is for such malpositions to be 
righted either before labor sets in, or in the early period of labor ; but 
it is quite easy to understand how any persistent pressure, applied in 
the manner indicated, may perpetuate a position which otherwise 
would have been only temporary. 

1 Left and right refer in this nomenclature, as in all positions, to the left and right side of the 
mother without regard to that of the child. 

2 Nouv. Arch. d'Obstet. et Gyn., 1889. 3 Annal. d'Hyg. pub. et de Med., Jan., 1879. 



PRESENTATIONS OF SHOULDER, ETC. 343 

Prognosis and Frequency. — According to Churchill's statistics, 
shoulder presentations occur about ouce in 260 cases ; that is, only 
slightly less frequently than those of the face. Spiegelberg found it 
1 in 180 ; while in France the combined statistics of several accoucheurs 
show a frequency of 1 in 117. The prognosis to both the mother and 
child is much more unfavorable ; for he estimates that out of 235 cases, 
1 in 9 of the mothers and half the children were lost. The prognosis 
in each individual case will, of course, vary much with the period of 
delivery at which the malposition is recognized. If detected early, 
interference is easy, and the prognosis ought to be good ; whereas there 
are few obstetric difficulties more trying than a case of shoulder pre- 
sentation, in which the necessary treatment has been delayed until the 
presenting part has been tightly jammed into the cavity of the pelvis. 

Diagnosis.— Bearing this fact in mind, the jiaraniount necessity of 
an accurate diagnosis will be apparent ; and it is specially important 
that we should be able not only to detect that a shoulder or arm is pre- 
senting, but that we should, if possible, determine which it is, and how 
the body and head of the child are placed. The existence of a shoulder 
presentation is not generally suspected until the first vaginal examina- 
tion is made during labor. The practitioner will then be struck with 
the absence of the rounded mass of the foetal head, and, if the os be 
opened and the membranes protruding, by their elongated form, which 
is common to this and to other malpresentations. If the presenting 
part be too high to reach, as is often the case at an early period of 
labor, an endeavor should at once be made to ascertain the foetal posi- 
tion by abdominal examination. This is the more important as it is 
much more easy to recognize presentations of the shoulder in this way 
than those of the breech or foot ; and, at so early a period, it is often 
not only possible but comparatively easy, to alter the position of the 
foetus by abdominal manipulation alone and thus avoid the necessity 
of the more serious form of version. The method of detecting a 
shoulder presentation by examination of the abdomen has already been 
described (p. 130), and need not be repeated. The chief points to look 
for are, the altered shape of the uterus, and two solid masses, the head 
and the breech, one in either iliac fossa. The facility with which these 
parts may be recognized varies much in different patients. In thin 
women, with lax abdominal parietes, they can be easily felt, while in 
very stout women it may be impossible. Failing this method, we must 
rely on vaginal examinations ; although, before the membranes are 
ruptured, and when the presenting part is high in the pelvis, it is not 
always easy to gain accurate information in this way. The difficulty 
is increased by the paramount importance of retaining the membranes 
intact as long as possible. It should be remembered, therefore, that 
when a presentation of the superior extremity is suspected, the neces- 
sary examinations should only be made in the intervals between the 
pains when the membranes are lax, and never when they are rendered 
tense by the uterine contractions. 

As either the shoulder, the elbow, or the hand may present, it will 
be best to describe the peculiarities of each separately, and the means 
of distinguishing to which side of the body the presenting part 
belongs. 



341 LABOR. 

1. The shoulder is recognized as a round smooth prominence, at 
one point of which may often be felt the sharp edge of the acromion. 
If the finger can be passed sufficiently high, it may be possible to feel 
the clavicle, and the spine of the scapula. A still more complete ex- 
amination may enable us to detect the ribs and the intercostal spaces, 
which would be quite conclusive as to the nature of the presentation, 
since there is nothing resembling them in any other part of the body. 
At the side of the shoulder, the hollow of the axilla may generally be 
made out. 

In order to ascertain the position of the child, we have to find out 
in which iliac fossa the head lies. This may be done in two ways : 
1st, the head may be felt through the abdominal parietes by palpation ; 
and 2d, since the axilla always points toward the feet, if it point to 
the left side the head must lie in the right iliac fossa ; if to the right, 
the head must be placed in the left iliac fossa. Again, the spine of the 
scapula must correspond to the back of the child, the clavicle to its 
abdomen : and, by feeling one or the other, we know whether we have 
to do with a dorso-anterior or dorso-posterior position. If we cannot 
satisfactorily determine the position by these means, it is quite legiti- 
mate practice to bring down the arm carefully, provided the membranes 
are ruptured, so as to examine the hand, which will be easily recognized 
as right or left. This expedient will decide the point ; but it is one 
which it is better to avoid, if possible, for it not only slightly increases 
the difficulty of turning, although perhaps not very materially, but the 
arm might possibly be injured in the endeavor to bring it down. 

The only part of the body likely to be taken for the shoulder is the 
breech ; but in that its larger size, the groove in which the genital 
organs lie, the second prominence formed by the other buttock, and the 
sacral spinous processes, are sufficient to prevent a mistake. 

2. The elbow is rarely felt at the os, and may be readily recognized 
by the sharp prominence of the olecranon, situated between two lesser 
prominences, the condyles. As the elbow always points toward the 
feet, the position of the foetus can be easily ascertained. 

3. The hand is easy to recognize, and can only be confounded with 
the foot. It can be distinguished by its borders being of the same 
thickness, by the fingers being wider apart and more readily separated 
from each other than the toes, and above all by the mobility of the 
thumb, which can be carried across the palm, and placed in apposition 
with each of the fingers. 

It is not difficult to tell which hand is presenting. If the hand be in 
the vagina, or beyond the vulva, and within easy reach, we recognize 
which it is by laying hold of it as if we were about to shake hands. If 
the palm lie in the palm of the practitioner's hand, with the two thumbs 
in apposition, it is the right hand ; if the back of the hand, it is the 
left. Another simple way is for the practioner to imagine his own 
hand placed in precisely the same position as that of the foetus ; and 
this will readily enable him to verify the previous diagnosis. A 
simple rule tells us how the body of the child is placed, for, provided 
we are sure the hand is in a state of supination, the back of the hand 
points to the back of the child, the palm to its abdomen, the thumb to 
the head, and the little finger to the feet. 



PRESENTATIONS OF SHOULDER, ETC. 345 

Mechanism. — It is perhaps hardly proper to talk of a mechanism 
of shoulder presentations, since, if left unassisted, they almost in- 
variably lead to the gravest consequences. Still, Xature is not entirely 
at fault even here, and it is well to study the means she adopts to 
terminate these malpositions. 

Terminations of Shoulder Presentation. — There are two possible 
terminations of shoulder presentation. In one, known as spontaneous 
version, some other part of the foetus is substituted for that originally 
presenting ; in the other, spontaneous evolution, the foetus is expelled 
by being squeezed through the pelvis, without the originally presenting 
part being withdrawn. It cannot be too strongly impressed on the 
mind that neither of these can be relied on in practice. 

Spontaneous version may occasionally occur before, or immediately 
after, the rupture of the membranes, when the foetus is still readily 
movable within the cavity of the uterus. A few authenticated cases 
are recorded in which the same fortunate issue took place after the 
shoulder had been engaged in the pelvic brim for a considerable time, 
or even after prolapse of the arm ; but its probability is necessarily 
much lessened under such circumstances. Either the head or the 
breech may be brought down to the os in place of the original pres- 
entation. 

The precise mechanism of spontaneous version, or the favoring 
circumstances, are not sufficiently understood to justify any positive 
statement with regard to it. 

Cazeaux believed that it is produced by partial or irregular contrac- 
tion of the uterus, oue side contracting energetically, while the other 
remains inert, or only contracts to a slight degree. To illustrate how 
this may effect spontaneous version, let us suppose that the child is 
lying with the head in the left iliac fossa. Then if the left side of the 
uterus should contract more forcibly than the right, it would clearly 
tend to push the head and shoulder to the right side, until the head 
came to present instead of the shoulder. A very interesting case is 
related by Geneuil, 1 in which he was present during spontaneous 
version, in the course of which the breech was substituted for the left 
shoulder more than four hours after the rupture of the membranes. 
In this case the uterus was so tightly contracted that version was im- 
possible. He observed the side of the uterus opposite the head con- 
tracting energetically, the other remaining flaccid, and eventually the 
case ended without assistance, the breech presenting. The natural 
moulding action of the uterus, and the greater tendency of the long 
axis of the child to lie in that of the uterus, no doubt assist the trans- 
formation, and much must depend on the mobility of the foetus in any 
individual case. 

That such changes often take place in the latter weeks of pregnancy, 
and before labor has actually commenced, is quite certain, and they are 
probably much more frequent than is generally supposed. When spon- 
taneous version does occur, it is, of course, a most favorable event ; 
and the termination and prognosis of the labor are then the same as if 
the head or breech had originally presented. 

1 Anal, de Gynec, torn. v. p. 468. 



346 



LABOR. 



Spontaneous Evolution. — The mechanism of spontaneous evolu- 
tion, since it was first clearly worked out by Douglas, has been so 
often and carefully described that we know precisely how it occurs. 
Although every now and then a case is recorded in which a living 
child has been born by this means, such an event is of extreme rarity; 
and there is no doubt of the accuracy of the general opinion, that spon- 
taneous evolution can only happen when the pelvis is unusually roomy 
and the child small ; and that it almost necessarily involves the death 
of the foetus, on account of the immense pressure to which it is sub- 
jected. 

Two varieties are described, in one of which the head is first born, 



Fig. 123. 




Spontaneous evolution. (After Chiara.) This drawing was made from a patient who died 
undelivered, the body being frozen and bisected. 

in the other the breech ; in both the originally presenting arm remained 
prolapsed. The former is of extreme rarity, and is believed only to 
have happened with very premature children, whose bodies were small 
and flexible, and when traction had been made on the presenting arm. 
Under such circumstances it can hardly be called a natural process, 
and we may confine our attention to the latter and more common 
variety. 

What takes place is as follows: The presenting arm and shoulder 



PRESENTATIONS OF SHOULDER, ETC. 347 

are tightly jammed down, as far as is possible, by the uterine contrac- 
tions, and the head becomes strongly flexed on the shoulder. As much 
of the body of the foetus as the pelvis will contain becomes engaged, 
and then a movement of rotation occurs, which brings the body of the 
child nearly into the anteroposterior diameter of the pelvis (Fig. 123). 
The shoulder projects under the arch of the pubis, the head lying above 
the symphysis, and the breech near the sacro-iliac synchondrosis. It 
is essential that the head should lie forward above the pubes, so that 
the length of the neck may permit the shoulder to project under the 
pubic arch, without any part of the head entering the pelvic cavity. 
The shoulder and neck of the child now become fixed points, around 
which the body of the child rotates, and the whole force of the uterine 
contractions is expended on the breech. The latter, with the body, 
therefore, becomes more and more depressed, until, at last, the side of 
the thorax reaches the vulva, and, followed by the breech and inferior 
extremities, is slowly pushed out. As soon as the limbs are born the 
head is easily expelled. 

The enormous pressure to which the body is subjected in this process 
can readily be understood. As regards the practical bearings of this 
termination of shoulder presentations, all that need be said is, that, if 
we should happen to meet with a case in which the shoulder and 
thorax were so strongly depressed that turning was impossible, and in 
which it seemed that Nature was endeavoring to effect evolution, we 
should be justified in aiding the descent of the breech by traction on 
the groin, before resorting to the difficult and hazardous operation of 
embryotomy and decapitation. 

Treatment. — It is unnecessary to describe specially the treatment 
of shoulder presentation, since it consists essentially in performing the 
operation of turning, which is fully described elsewhere. It is only 
needful here to insist on the advisability of performing the operation 
in the way which involves the least interference with the uterus. 
Hence, if the nature of the case be detected before the membranes are 
ruptured, an endeavor should be made — and ought generally to suc- 
ceed — to turn by external manipulation only. If we can succeed in 
bringing the breech or head over the os in this way, the case will be 
little more troublesome than an ordinary presentation of these parts. 
Failing in this, turning by combined external and internal manipula- 
tion should be attempted ; and the introduction of the entire hand 
should be reserved for those more troublesome cases in which the 
waters have long drained away, and in which both these methods are 
inapplicable. 

Should all these means fail, we must resort to the mutilation of the 
child by embryulcia or decapitation, probably the most difficult and 
dangerous of all obstetric operations. In fourteen cases in the United 
States the Cesarean section has been performed under these circum- 
stances, with a successful result to the mother in ten. In seven cases 
the arm protruded, in three the pelvis was small, and in two it was 
deformed. Three of the women were subsequently delivered naturally. 1 

1 Harris, note to 6th American edition. 



348 LABOR. 

Complex Presentations. — There are various so-called complex pres- 
entations in which more than one part of the foetal body presents. Thus 
we may have a hand or a foot presenting with the head, or a foot and 
hand presenting simultaneously. The former do not necessarily give 
rise to any serious difficulty, for there is generally sufficient room for 
the head to pass. Indeed, it is unlikely that either the hand or foot 
should enter the pelvic brim with the head, unless the head was unusu- 
ally small, or the pelvis more than ordinarily capacious. As regards 
treatment, it is, no doubt, advisable to make an attempt to replace the 
hand or foot by pushing it gently above the head in the intervals 
between the pains, and to maintain it there until the head be fully 
engaged in the pelvic cavity. The engagement of the head can be 
hastened by abdominal pressure, which will prove of great value. 
Failing this, all we can do is to place the presenting member at the 
part of the pelvis where it will least impede the labor, and be the least 
subjected to pressure ; and that will generally be opposite the temple 
of the child. As it must obstruct the passage of the head to a certain 
extent, the application of the forceps may be necessary. When the 
feet and hands present at the same time, in addition to the confusing 
nature of the presentation from so many parts being felt together, there 
is the risk of the hands coming down, and converting the case into one 
of arm presentation. It is the obvious duty of the accoucheur to pre- 
vent this by insuring the descent of the feet, and traction should be 
made on them, either with the fingers or with a fillet, until their descent, 
and the ascent of the hands, are assured. 

Dorsal Displacement of the Arm. — In connection with this sub- 
ject may be mentioned the curious dorsal displacement of the arm first 
described by Sir James Simpson, 1 in which the forearm of the child 
becomes thrown across and behind the neck. The result is the forma- 
tion of a ridge or bar, which prevents the descent of the head into the 
pelvis by hitching against the brim (Fig. 124). The difficulty of 
diagnosis is very great, for the cause of obstruction is too high up to 
be felt. But if we meet with a case in which the pelvis is roomy and 
the pains strong, and yet the head does not descend after an adequate 
time, a full exploration of the cause is essential. For this purpose we 
would naturally put the patient under chloroform, and pass the hand 
sufficiently high. We might then feel the arm in its abnormal posi- 
tion. That was what took place in a case under my own care, in 
which I failed to get the head through the brim with the forceps, and 
eventually delivered by turning. The same course was adopted by 
my friend Mr. Jardine Murray in a similar case. 2 Simpson advises 
that the arm should be brought down so as to convert the case into an 
ordinary hand and head presentation. This, if the arm be above the 
brim, must always be difficult, and I believe the simpler and more 
effective plan is podalic version. A similar displacement may cause 
some difficulty in breech presentations, and after turning (Fig. 125). 
Delay here is easier of diagnosis, since the obstacle to the expulsion 
will at once lead to careful examination. By carrying the body of the 

i Selected Obstet. Works, vol. i. 2 Med. Times and Gaz., 1861. 



PRESENTATION'S OF SHOULDER, ETC. 



349 



child well backward, so as to enable the finger to pass behind the 
symphysis pubis and over the shoulder, it will generally be easy to 
liberate the arm. 



Fig. 124. 



Fig. 125. 





Dorsal displacement of the arm. 



Dorsal displacement of the arm in footling 
presentations. ''After Baknes.) 



Prolapse of the Umbilical Cord. — It occasionally happens that 
the umbilical cord falls down past the presenting part (Fig. 126), and 
is apt to be pressed between it and the walls of the pelvis. The conse- 
quence is that the foetal circulation is seriously interfered with, and the 
death of the child from asphyxia is a common result. Hence prolapse 
of the funis is a very serious complication of labor in so far as the 
child is concerned. 

Frequency. — Fortunately it is not a very frequent occurrence. 
Churchill calculates that out of over 105,000 deliveries it was met 
with once in 240 cases, and Scanzoni once in 254. Its frequency 
varies much under different circumstances, and in different places. 
AVe find from Churchill's figures a remarkable diiference in the pro- 
portional number of cases observed in France, England, and Germany 
— viz., 1 in 446J, 1 in 207J, and 1 in 156, respectively. Great as is 
the proportion referred to Germany in these figures, it has been found 
to be exceeded in special districts. Thus Engelmann records 1 case out 
of 94 labors in the Lying-in Hospital at Berlin, and Michaelis 1 in DO 
in that of Kiel. These remarkable differences are at first sight not 
easy to account for. Dr. Simpson suggests, with considerable show of 



350 



LABOR 



probability, that the difference in frequency in England, France, and 
Germany may depend on the varying positions in which lying-in 
women are placed during labor in each country. In France, where, 
although the patient is laid on her back, the pelvis is kept elevated, 
the complication occurs least frequently ; in England, where she lies 
on her side, more often ; and in Germany, where she is placed on her 
back with her shoulders raised, most often. The special frequency of 
prolapsed funis in certain districts, as in Kiel, is supposed by Engel- 
mann 1 to depend on the prevalence of rickets, and consequently of 
deformed pelvis, which we shall presently see is probably one of the 
most frequent and important causes of the accident. 

Prognosis. — With regard to the danger attending prolapsed funis, 
as far as the mother is concerned, it may be said to be altogether unim- 
portant; but the universal experience of obstetricians points to the 



Fig. 126 




Prolapse of the umbilical cord. 

great risk to which the child is subjected. Scanzoni calculates that 45 
per cent, only of the children were saved ; Churchill estimated the 
number at 47 per cent. ; thus, under the most favorable circumstances, 
this complication leads to the death of more than half the children. 
Engelmann found that out of 202 vertex presentations only 36 per 
cent, of the children survived. The mortality was not nearly so great 
in other presentations ; 68 per cent, of the cases in which the child pre- 
sented with the feet were saved, and 50 per cent, in original shoulder 
presentations. The reason of this remarkable difference is, doubtless, 
that in vertex presentations the head fits the pelvis much more com- 
pletely, and subjects the cord to much greater pressure ; while in other 
presentations the pelvis is less completely filled, and the interference 

1 Amer. Journ. of Obstetrics, vol. vi. pp. 409, 540. 



PRESENTATIONS OF SHOULDER, ETC. 351 

with the circulation in the cord is not so great. Besides, in the latter 
case the complication is detected early, and the necessary treatment 
sooner adopted. 

The foetal mortality is considerably greater in first labors — a result 
to be expected on account of the greater resistance of the soft parts, 
and the consequent prolongation of the labor. 

The causes of prolapse of the funis are any circumstances which 
prevent the presenting part accurately fitting the pelvic brim. Hence 
it is much more frequent in face, breech, or shoulder than in vertex 
presentations, and is relatively more common in footling and shoulder 
presentations than in any other. Amongst occasional accidental pre- 
disposing causes may be mentioned early rupture of the membranes, 
especially if the amount of liquor amnii be excessive, as the sudden 
escape of the fluid washes down the cord ; undue length of the cord 
itself ; or an unusually low placental attachment. Engelmann attaches 
great importance to slight contraction of the pelvis, and states that in 
the Berlin Lying-in Hospital, where accurate measurements of the 
pelvis were taken in all cases, it was almost invariably found to exist. 
The explanation is evident, since one of the first results of pelvic con- 
traction is to prevent the ready engagement of the presenting part in 
the pelvic brim. 

The diagnosis of cord presentation is generally devoid of difficulty ; 
but if the membranes are still unruptured, it may not always be quite 
easy to determine the precise nature of the soft structures felt through 
them, as they recede from the touch. If the pulsations of the cord 
can be felt through the membranes, all difficulty is removed. After 
the membranes are ruptured, there is nothing for which it can well be 
mistaken. 

The important point to determine in such a case is whether the cord 
be pulsating or not ; for if pulsations have entirely ceased, the inference 
is that the child is dead, and the case may then be left to Nature without 
further interference. It is of importance, however, to be careful ; for, 
if the examination be made during a pain, the circulation might be 
only temporarily arrested. The examination, therefore, should be 
made during an interval, and a loop of the cord pulled clowu, if 
necessary, to make ourselves absolutely certain on this point. 

The amount of the prolapse varies much. Sometimes only a knuckle 
of the cord, so small as to escape observation, is engaged between the 
pelvis and presenting part. Under such circumstances the child may 
be sacrificed without any suspicion of danger having arisen. More 
often the amount prolapsed is considerable ; sometimes so as to lie in 
the vagina in a long loop, or even to protrude altogether beyond the 
vulva. 

Treatment. — In the treatment the great indication is to prevent 
the cord from being unduly pressed on, and all our endeavors must 
have this object in view. If the presentation be detected before the 
full dilatation of the cervix, and when the membranes are unruptured, 
we must try to keep the cord out of the way; to preserve the mem- 
branes intact as long as possible, since the cord is tolerably protected 
as long as it is surrounded by the liquor amnii; and to secure the 



352 



LABOR. 



complete dilatation of the os, so that the presenting part may engage 
rapidly and completely. 

Much may be done at this time by the postural treatment, which 
Ave owe chiefly to the ingenuity of Dr. T. Gaillard Thomas, of New 
York, whose writings familiarized the profession with it, although it 
appears that a somewhat similar plan had been occasionally adopted 
previously. Dr. Thomas's method is based on the principle of caus- 
ing the cord to slip back into the uterine cavity by its own weight. 
For this purpose the patient is placed on her hands and knees, with 
the hips elevated, and the shoulders resting on a lower level (Fig. 
127). The cervix is then no longer the most dependent portion of the 

Fig. 127. 




Postural treatment of prolapse of the cord. 

uterus, and the anterior wall of the uterus forms an inclined plane 
down which the cord slips. The success of this manoeuvre is some- 
times very great, but by no means always so. It is most likely to 
succeed when the membranes are unruptured. If, when adopted, the 
cord slip away, and the os be sufficiently dilated, the membranes may 
be ruptured, and engagement of the head produced by properly 
applied uterine pressure. Sometimes the position is so irksome that 
it is impossible to resort to it. Postural treatment is not even then 
altogether impossible, for by placing the patient on the side opposite 
it is impossible to resort to it. Another method of using postural 
treatment, perhaps simpler and less irksome to the patient, is by placing 
her in the Trendelenburg's position, in which the pelvis is elevated and 
the shoulders lowered. This can be easily enough done, either by 
packing pillows under the pelvis, the patient lying on her back, or by 
elevating the thighs over the back of a chair placed on the bed in an 
inverted position. Even after the membranes are ruptured, postural 
treatment in one form or another may succeed ; and, as it is simple and 
harmless, it should certainly be always tried. Attempts at reposition, 
by one or other method described below, may also occasionally be facili- 
tated by trying them when the patient is placed in the knee-shoulder 
position. 



PRESENTATION OF SHOULDER, ETC 



353 



Failing by postural treatment, or in combination with it, it is quite 
legitimate to make an attempt to place the cord beyond the reach of 
dangerous pressure by other methods. Unfortunately reposition is 
too often disappointing, difficult to effect, and very frequently, even 
when apparently successful, shortly followed by a fresh descent of the 
cord. Provided the os be fully dilated and the presenting head 
engaged in the pelvis (for reposition may be said to be hopeless when 
any other part presents), perhaps the best way is to attempt it by the 
hand alone. Probably the simplest and most effectual method is that 
recommended by McClintock and Hardy, who advise that the patient 
should lie on the opposite side to the prolapsed cord, which should 
then be drawn toward the pubes as being the shallowest part of the 
pelvis. Two or three fingers may then be used to 
push the cord past the head, and as high as they 
can reach. They must be kept in the pelvis until 
a pain comes on, and then very gently withdrawn, 
in the hope that the cord may not again prolapse. 
During the pain external pressure may very prop- 
erly be applied to favor descent of the head. This 
manoeuvre may be repeated during several suc- 
cessive pains, and may eventually succeed. The 
attempt to hook the cord over the foetal limbs, or to 
place it in the hollow of the neck, recommended 
in many works, involves so deep an introduction 
of the hand that it is obviously impracticable. 

Various complex instruments have been in- 
vented to aid reposition (Fig. 128), but even if 
we possessed them they are not likely to be at 
hand when the emergency arises. A simple in- 
strument may be improvised out of an ordinary 
male elastic catheter, by passing the two ends of 
a piece of string through it, so as to leave a loop 
emerging from the eye of the catheter. This is 
passed through the loop of prolapsed cord, and 
then fixed in the eye of the catheter by means of 
the stilette. The cord is then pushed up into the 
uterine cavity by the catheter, and liberated by 
withdrawing the stilette. Another simple instru- 
ment may be made by cutting a hole in a piece of 
whalebone. A piece of tape is then j^assed through 
the loop of the cord and the ends threaded through the eye cut in the 
whalebone. By tightening the tape the whalebone is held in close 
apposition to the cord, and the whole is passed as high as possible into 
the uterine cavity. The tape can easily be liberated by pulling one 
end. If preferred, the cord can be tied to the whalebone, which is 
left in utero until the child is born. Nothing need be said as to the 
various other methods adopted for keeping up the cord, such as the 
insertion of pieces of sponge, or tying the cord in a bag of soft leather, 
since they are generally admitted to be quite useless. 

It only too often happens that all endeavors at reposition fail. The 

23 




Braun's apparatus for 
replacing the cord. 



354 LABOR. 

subsequent treatment must then be guided by the circumstances of the 
case. If the pelvis be roomy, and the pains strong, especially in a 
multipara, we may often deem it advisable to leave the case to Nature, 
in the hope that the head may be pushed through before pressure on 
the cord has had time to prove fatal to the child. Under such circum- 
stances the patient should be urged to bear down, and the descent of the 
head be promoted by uterine pressure, so as to get the second stage 
completed as soon as possible. If the head be within easy reach, the 
application of the forceps is quite justifiable, since delay must neces- 
sarily involve the death of the child. During this time the cord should 
be placed, if possible, opposite one or the other sacro-iliac synchon- 
drosis according to the position of the head, as being the part of the^ 
pelvis where there is most room, and pressure would consequently 
be least prejudicial. If we have to do with a case in which the head 
has not descended into the pelvis, and postural treatment and re- 
position have both failed, provided the os be fully dilated, and other 
circumstances be favorable, turning would undoubtedly offer the best 
chance to the child. This treatment is strongly advocated by Engel- 
mann, who found that 70 per cent, of the children delivered in this 
way were saved. There can be no question that, so far as the inter- 
ests of the child are concerned, it is, under the circumstances indicated, 
by far the best expedient. Turning, however, is by no means always 
devoid of a certain risk to the mother, and the performance of the 
operation, in any particular case, must be left to the judgment of the 
practitioner. A fully dilated os, with membranes unruptured, so that 
version could be performed by the combined method without the 
introduction of the hand into the uterus, w T ould be unquestionably the 
most favorable state. If it be not deemed proper to resort to it, all 
that can be done is to endeavor to save the cord from pressure as much 
as possible, by one or another of the methods already mentioned. 



CHAPTEE IX. 

PROLONGED AND PRECIPITATE LABORS. 

Among the difficulties connected with parturition there are none of 
more frequent occurrence, and none requiring more thorough knowl- 
edge of the physiology and pathology of labor, than those arising from 
deficient or irregular action of the expulsive powers. The importance 
of studying this class of labors will be seen when we consider the 
numerous and very diverse causes which produce them. 

Evil Effects of Prolonged Labor. — That the mere prolongation 
of labor is in itself a serious thing, is becoming daily more and more 
an acknowledged axiom of midwifery practice ; and that this is so is 
evident when Ave contrast the statistical returns of such institutions as 
the Rotunda Lying-in Hospital of late years, with those which were 



PROLONGED AND PRECIPITATE LABORS. 355 

published some twenty or thirty years ago. It may be fairly assumed 
that the practice of the distinguished heads of that well-known school 
represents the most advanced and scientific opinions of the day. "When 
Ave find that, less than thirty years ago, 1 forceps were not used more 
than once in 310 labors, while, according to the report for 1873, the 
late master applied them once in 8 labors, it is apparent how great is 
the change which has taken place. 

Labor may be prolonged from an immense number of causes, the 
principal of which will require separate study. Some depend simply 
on defective or irregular action of the uterus ; others act by opposing 
the expulsion of the child, as, for example, undue rigidity of the par- 
turient passages, tumors, bony deformity, and the like. Whatever the 
source of delay, a train of formidable symptoms is developed which 
are fraught with peril both to the mother and the child. As regards 
the mother, they vary much in degree and in the rapidity with which 
they become established. In many cases, in which the action of the 
uterus is slight, it may be long before serious results follow ; while in 
others, in which a strongly-acting organ is exhausting itself in futile 
endeavors to overcome an obstacle, the worst signs of protraction may 
come on with comparative rapidity. 

The stage of labor in which delay occurs has a marked effect 
in the production of untoward symptoms. It is a well-established 
feet that prolongation is of comparatively small consequence to either 
the mother or child in the first stage, when the membranes are still 
intact, and when the soft parts of the mother, as well as the body of 
the child, are protected by the liquor amnii from injurious pressure ; 
whereas if the membranes have ruptured, prolongation becomes of the 
utmost importance to both as soon as the head has entered the pelvis, 
when the uterus is strongly excited by reflex stimulation, when the 
maternal soft parts are exposed to continuous pressure, and when the 
tightly contracted uterus presses firmly on the foetus and obstructs the 
placental circulation. It is in reference to the latter class of cases that 
the change of practice, already alluded to, has taken place, with the 
most beneficial results both to mother and child. 

It must not be assumed, however, that prolongation of labor is 
never of any consequence until the second stage has commenced. The 
fallacy of such an opinion was long ago shown by Simpson, who 
proved in the most conclusive way, that both the maternal and foetal 
mortality were greatly increased in proportion to the entire length of 
the labor ; and all practical accoucheurs are familiar with cases in which 
symptoms of gravity have arisen before the first stage is concluded. 
Still, relatively speaking, the opinion indicated is undoubtedly correct. 

In the present chapter we have to do only with those causes of 
delav connected with the expulsive powers. Inasmuch, however, as 
the injurious effects of protraction are similar in kind whatever be 
the cause, it will save needless repetition if we consider, once for all, 
the train of symptoms that arise whenever labor is unduly prolonged. 

Delay in the First Stage is Rarely Serious. — As long as the 

1 This refers to the date of the first edition of this work. 1870. 



356 LABOR. 

delay is in the first stage only, with rare exceptions, no symptoms of 
real gravity arise for a length of time ; it may be even for clays. 
There is often, however, a partial cessation of the pains, which, in 
consequence of temporary exhaustion of nervous force, may even 
entirely disappear for many consecutive hours. Under such circum- 
stances, after a period of rest, either natural or produced by suitable 
sedatives, they recur with renewed vigor. 

Symptoms of Protraction in the Second Stage. — A similar 
temporary cessation of the pains may often be observed after the head 
has passed through the os uteri, to be also followed by renewed vigor- 
ous action after rest. But now any such irregularity must be much 
more anxiously watched. In the majority of cases any marked alter- 
ation in the force and frequency of the pains at this period indicates 
a much more serious form of delay, which in no long time is accom- 
panied by grave general symptoms. The pulse begins to rise, the skin 
to become hot and dry, the patient to be restless and irritable. The 
longer the delay, and the more violent the efforts of the uterus to 
overcome the obstacle, the more serious does the state of the patient 
become. The tongue is loaded with fur, and in the worst cases dry 
and black ; nausea and vomiting often become marked ; the vagina 
feels hot and dry, the ordinary abundant mucous secretion being 
absent ; in severe cases it may be much swollen, and if the presenting 
part be firmly impacted, a slough may even form. Should the patient 
still remain undelivered, all these symptoms become greatly intensi- 
fied ; the vomiting is incessant, the pulse is rapid and almost imper- 
ceptible, low muttering delirium supervenes, and the patient eventually 
dies with all the worst indications of profound irritation and exhaustion. 

So formidable a train of symptoms, or even the slighter degrees of 
them, should never occur in the practice of the skilled obstetrician ; 
and it is precisely because a more scientific knowledge of the process 
of parturition has taught the lesson that, under such circumstances, 
prevention is better than cure, that earlier interference has become so 
much more the rule. 

Those who taught that nothing should be done until Nature had 
had every possible chance of effecting delivery, and who, therefore, 
allowed their patients to drag on through many weary hours of labor, 
at the expense of great exhaustion to themselves, and imminent risk 
to their offspring, made much capital out of the time-honored maxim 
that " meddlesome midwifery is bad." When this proverb is applied 
to restrain the rash interference of the ignorant, it is of undeniable 
value ; but when it is quoted to prevent the scientific action of the 
experienced, who know precisely when and why to interfere, and who 
have acquired the indispensable mechanical skill, it is sadly mis- 
applied. 

State of the Uterus in Protracted Labor. — The nature of the 
pains and the state of the uterus, in cases of protracted labor, are 
peculiarly worthy of study, and have been very clearly pointed out 
by Dr. Braxton Hicks. 1 He shows that, when the pains have appar- 

1 Obstet. Trans., vol. ix. p. 207. 



PROLONGED AND PRECIPITATE LABORS. 357 

ently fallen off and become few and feeble, or have entirely ceased, 
the uterus is in a state of continuous or tonic contraction, and that the 
irritation resulting from this is the chief cause of the more marked 
symptoms of powerless labor. If, in a case of the kind, the uterus 
be examined by palpation, it will be found firmly contracted between 
the pains. The correctness of this observation is beyond question, 
and it will, no doubt, often be an important guide in treatment. 
Under such circumstances instrumental interference is imperatively 
demauded. 

Causes. — In considering the causes of protracted labor, it will be 
well first to discuss those which affect the expulsive powers alone, 
leaving those depending on morbid states of the passages for future 
consideration ; bearing in mind, however, that the results, as regards 
both the mother and the child, are identical, whatever may be the 
cause of delay. 

The general constitutional state of the patient may materially in- 
fluence the force and efficiency of the pains. Thus it not unfrequently 
happens that they are feeble and ineffective in women of very weak 
constitution, or who are much exhausted by debilitating disease. 
Cazeaux pointed out that the effects of such general conditions are 
often more than counterbalanced by flaccidity and want of resistance 
of the tissues, so that there is less obstacle to the passage of the child. 
Thus, in phthisical patients reduced to the last stage of exhaustion, 
labor is not unfrequently surprisingly easy. 

Long residence in tropical climates causes uterine inertia, in conse- 
quence of the enfeebled nervous power it produces. It is a common 
observation that European residents in India are peculiarly apt to 
suffer from post-partum hemorrhage from this cause. The general 
mode of life of patients has an unquestionable effect ; and it is certain 
that deficient and irregular uterine action is more common in women 
of the higher ranks of society, who lead luxurious, enervating lives, 
than in women whose habits are of a more healthy character. 

Tyler Smith lays much stress on frequent childbearing as a cause 
of inertia, pointing out that a uterus which has been very frequently 
subjected to the changes connected with pregnancy, is unlikely to be 
in a typically normal condition. It is doubtful, however, whether the 
uterus of a perfectly healthy woman is affected in this way ; certainly, 
if childbearing had undermined her general health, the labors are 
likely to be modified also. 

Age has a decided effect. In the very young the pains are apt to be 
irregular, on account of imperfect development of the uterine muscles. 
Labor taking place for the first time in women advanced in life is also 
apt to be tedious, especially in the first stage, bul not by any means so 
invariably as is generally believed. The apprehensions of such patients 
are often agreeably falsified, and where delay does occur, it is probably 
more often referable to rigidity and toughness of the parturient passages 
than to feebleness of the pains. 

Morbid states of the prima? via? frequently cause irregular, painful, 
and feeble contractions. A loaded state of the rectum has a remarkable 
influence, as evidenced by the sudden and distinct change in the char- 



358 LABOR. 

acter of the labor which often follows the use of suitable remedies. 
Undue distention of the bladder may act in the same way, more espe- 
cially in the second stage. When the urine has been allowed to accu- 
mulate unduly, the contraction of the accessory muscles of parturition 
often causes such intense suffering, by compressing the distended viscus, 
that the patient is absolutely unable to bear down. Hence the labor 
is carried on by uterine contractions alone, slowly, and at the expense 
of much suffering. A similar interference with the action of the 
accessory muscles is often produced by other causes. Thus if labor 
comes on when the patient is suffering from bronchitis or other chest 
disease, she may be quite unable to fix the chest by a deep inspiration, 
and the diaphragm and other accessory muscles cannot act. In the 
same way they may be prevented from acting when the abdomen is 
occupied by an ovarian tumor, or by ascitic fluid. 

Mental conditions have a very marked effect. This is so commonly 
observed that it is familiar to the merest beginner in midwifery prac- 
tice. The fact that the pains often diminish temporarily on the 
entrance of the accoucheur is known to every nurse ; and so also undue 
excitement, the presence of too many people in the room, overmuch 
talking, have often the same prejudicial effect. Depression of mind, 
as in unmarried women, and fear and despondency in women who have 
looked forward with apprehension to the labor, are also common causes 
of irregular and defective action. 

Undue distention of the uterus from an excessive amount of liquor 
amnii not unfrequently retards the first stage, by preventing the uterus 
from contracting efficiently. When this exists, the pains are feeble 
and have little effect in dilating the cervix beyond a certain degree. 
This cause may be suspected when undue protraction of the first stage 
is associated with an unusually large size and marked fluctuation of 
the uterine tumor, through which the foetal limbs cannot be made out 
on palpation. On vaginal examination the lower segment of the 
uterus will be found to be very rounded and prominent, while the 
bag of membranes will not bulge through the os during the acme of 
the pain. 

A somewhat similar cause is undue obliquity of the uterus, which 
prevents the pains acting to the best mechanical advantage, and often 
retards the entry of the presenting part into the brim. The most 
common variety is anteversion, resulting from undue laxity of the 
abdominal parietes, which is especially found in women who have 
borne many children. Sometimes this is so excessive that the fundus 
lies oves the pubes, and even projects downward toward the patient's 
knees. The consequence is, that, when labor sets in, unless corrective 
means be taken, the pains force the head against the sacrum, instead 
of directing it into the axis of the pelvic inlet. Another common 
deviation is lateral obliquity, a certain degree of which exists in almost 
all cases, but sometimes it occurs to an excessive degree. Either of 
these states can readily be detected by palpation and vaginal examina- 
tion combined. In the former the os may be so high up, and tilted so 
far backward, that it may be at first difficult to reach it at all. 

Irregular and Spasmodic Pains. — Besides being feeble, the uterine 



PROLONGED AND PRECIPITATE LABORS. 359 

contractions, especially in the first stage, are often irregular and spas- 
modic, intensely painful, but producing little or no effect on the 
progress of the labor. This kind of case has been already alluded to 
in treating of the use of anaesthetics (p. 312), and is very common in 
highly nervous and emotional women of the upper classes. In such 
cases cocaine has been of late used as a local application with decided 
benefit. It appears to act by deadening the pain resulting from the 
stretching of the nerves of the cervix, or from slight cervical lacera- 
tions. It has no effect in relieving the suffering caused by uterine 
contraction. 1 It has been applied by means of a cotton-wool tampon 
steeped in a 2 per cent, solution, and placed against the os. A much 
better way of using it is by " Moore's cones" 2 made with cacao-butter, 
one of which is placed on the examining finger like a thimble, and 
inserted within the os, where it rapidly melts. Antipyrine has been 
frequently used in this kind of labor as a uterine sedative, but its 
beneficial effects appear to be doubtful. Auvard and Lefebvre, 3 who 
have carefully studied and reported cases, come to the conclusion that 
it cannot be compared in efficacy with chloral, although occasionally 
useful. It may be given in a dose of fifteen grains, repeated in two 
hours. Such irregular contractions do not necessarily depend on 
mental causes alone, and they often follow conditions producing irrita- 
tion, such as loaded bowels, too early rupture of the membranes, and 
the like. Dr. Trenholme, of Montreal,* believes that such irregular 
pains most frequently depend on abnormal adhesions between the 
decidua aud the uterine Avails, which interfere with the proper dilata- 
tion of the os, aud he has related some interesting cases in support of 
this theory. 

Treatment. — The mere enumeration of these various causes of pro- 
tracted labor will indicate the treatment required. Some of them, 
such as the constitutional state of the patient, age, or mental emotion, 
it is, of course, beyond the power of the practitioner to influence or 
modifv; but in every case of feeble or irregular uterine action, a careful 
investigation should be made with the view of seeing if any removable 
cause exist. For example, the effect of a large enema, when Ave sus- 
pect the existence of a loaded rectum, is often very remarkable; the 
pains frequently almost immediately changing in character, and a pre- 
viously lingering labor being rapidly terminated. 

Excessive distention of the uterus can only be treated by artificial 
evacuation of the liquor amnii ; and after this is done, the character of 
the pains often rapidly changes. This expedient is indeed often of 
considerable A^alue in cases in which the cervix has dilated to a cer- 
tain extent, but in which no further progress is made, especially if the 
bag of membranes does not protrude through the os during the pains, 
and the cervix itself is soft, and apparently readily dilatable. Under 
such circumstances, rupture of the membranes, even before the os is 
fully dilated, is often very useful. 

If Ave have reason to suspect morbid adhesions between the mem- 

1 " The A'alue of Cocaine in Obstetrics," by John Phillips. M.A., M.D. Lancet, Nov. 26, 1887. 

2 Brit. Med. Jonrn., vol. ii. p. 1140. 

3 Arch, de Tocol.. 1888, p. 649, and 1889, p. 505. 

4 Obst. Trans., vol. xiv. p. 231. 



360 LABOR. 

branes and the uterine walls, an endeavor must be made to separate 
them by sweeping the finger or a flexible catheter around the internal 
margin of the os, or puncturing the sac. The former expedient has 
been advocated by Dr. Inglis, 1 as a means of increasing the pains when 
the first stage is very tedious, and I have often practised it with marked 
success. Trenholme's observation affords a rationale of its action. 
The manoeuvre itself is easily accomplished, and, provided the os be 
not very high in the pelvis, does not give any pain or discomfort to 
the patient. 

Attention should always be paid to remedying any deviations of the 
uterus from its proper axis. If this be lateral, the proper course to 
pursue is to make the patient lie on the opposite side to that toward 
which the organ is pointing. In the more common anterior deviation 
she should lie on her back, so that the uterus may gravitate toward 
the spine, and a firm abdominal bandage should be applied. This 
prevents the organ from falling forward, while its pressure stimu- 
lates the muscular fibres to increased action ; hence it is often very 
serviceable when the pains are feeble, even if there be no antever- 
sion. 

In a frequent class of cases, especially in the first stage, the pains 
diminish in force and frequency from fatigue, and the indication then 
is to give a temporary rest, after which they recommence with renewed 
vigor. Hence an opiate, such as twenty minims of Battley's solu- 
tion, which often acts quickest when given in the form of enema, is 
frequently of the greatest possible value. If this secure a few hours' 
sleep the patient will generally awake much refreshed and invig- 
orated. This is a very old practice, and, at times, of great value. 
It is important to distinguish this variety of arrested pain from that 
dependent on actual exhaustion ; and this can be done by attention to 
the general condition of the patient, and especially by observing that 
the uterus is soft and flaccid in the intervals between the pains, and 
that there is none of the tonic contraction indicated by persistent hard- 
ness of the uterine parietes. When the pains are irregular, spasmodic, 
and excessively painful, without producing any real effect, opiates are 
also of great service ; and it is under such circumstances that chloral 
is especially valuable. 

Oxytocic Remedies. — Still a large number of cases will arise in 
which the absence of all removable causes has been ascertained, and in 
which the pains are feeble and ineffective. We must now proceed to 
discuss their management. The fault being the want of sufficient con- 
traction, the first indication is to increase the force of the pains. Here 
the so-called oxytocic remedies come into action ; and, although a large 
number of these have been used from time to time, such as borax, 
cinnamon, quinine, and galvanism, practically the only one in which 
reliance is generally placed is the ergot of rye. This has long been 
the favorite remedy for deficient uterine action, and it is a powerful 
stimulant of the uterine fibres. It has, however, very serious disad- 
vantages, and it is very questionable whether the risks to both mother 

1 Sydenham Society's Year-book. 



PROLONGED AND PRECIPITATE LABORS. 361 

and child do not more than counterbalance any advantages attending 
its use. The ergot is given in doses of fifteen or twenty grains of the 
freshly powdered drug infused in warm water, or in the more con- 
venient form of the liquid extract in doses of from twenty to thirty 
minims, or, still better, in the form of ergotine injected hypodermi- 
cally, three to four minims of the hypodermic solution being used for 
the purpose. In about fifteen minutes after its administration the 
pains generally increase greatly in force and frequency, and if the 
head be low in the pelvis, and if the soft parts offer no resistance, the 
labor may be rapidly terminated. 

Were its use always followed by this eifect there would be little or 
no objection to its administration. The pains, however, are different 
from those of natural labor, being strong, persistent, and constant. Its 
effect, indeed, is to produce that very state of tonic and persistent 
uterine contraction which has already been pointed out as one of the 
chief dangers of protracted labor. Hence, if from any cause the exhibi- 
tion of the drug be not followed by rapid delivery, a condition is pro- 
duced which is serious to the mother, and which is extremely perilous 
to the child, on account of the tonic contraction of the muscular fibres 
obstructing the utero-placental circulation. Dr. Hardy found that 
soon the foetal pulsations fall to 100, and, if delivery be long delayed, 
they commence to intermit. He also observed that when this occurred 
the child was always born dead, and found that the number of still- 
born children after ergot has been exhibited was very large ; for out 
of thirty eases in which he gave it in tedious labor, only ten of the 
children were born alive. Xor is its use by any means free from 
danger to the mother ; a not inconsiderable number of cases of rupture 
of the uterus have been attributed to its incautious use. Hence, if it 
is to be given at all, it is obvious that it must be with strict limita- 
tions, and after careful consideration. It is worthy of note that in the 
Rotunda Hospital in Dubliu, the use of ergot as an oxytocic before 
delivery has beeu prohibited by the late and present master. 

The cardinal point to remember is that it is absolutely contra-indi- 
cated unless the absence of all obstacles to rapid delivery has been 
ascertained. Hence, it is only allowable when the first stage is over, 
and the os fully dilated ; when the experience of former labors has 
proved the pelvis to be of ample size ; and when the perineum is soft 
and dilatable. Perhaps, as has been suggested, the administration of 
small doses of from five to ten minims of the liquid extract every ten 
minutes, until more energetic action sets in, might obviate some of 
these risks. 

The use of quinine as an oxytocic deserves much more attention 
than it has generally received. I frequently employ it in lingering 
labor with marked benefit, and it does not seem to have any of the 
bad effects of ergot. According to the observations of Dr. Albert H. 
Smith, in forty-two cases of parturition, it presented the following 
peculiar characteristic : 

It has no power in itself to excite uterine contractions, but simply 
acts as a general stimulant and promoter of vital energy and func- 
tional activity. Dr. R. Doyle, of Trinidad, recently writes to point 



362 LABOR. 

out that quinine given in malarial fever is constantly observed to pro- 
duce uterine contractions and abortion. 1 

In normal labor at full term, its administration in a dose of fifteen 
grains is usually followed in as many minutes by a decided increase in 
the force and frequency of the uterine contractions, changing in some 
instances a tedious, exhausting labor into one of rapid energy, ad- 
vancing to an early completion. 

It promotes the permanent tonic contraction of the uterus, after the 
expulsion of the placenta ; women that had flooded in former labors 
escaping entirely, there not having been an instance of post-partum 
hemorrhage in the whole forty- two cases. 

It also diminishes the lochial flow where it had been excessive in 
former labors, the change being remarked upon by the patients, and 
consequently lessens the severity of the after-pains. 

Cinchonism is very rarely observed as an effect of large doses in 
parturient women. 2 

Use of the Paradic Current. — The faradic current applied on 
cither side of the uterine tumor, midway between the anterior-superior 
spine of the ilium and the umbilicus, has recently been strongly recom- 
mended by Dr. Kilner, 3 not only as a means of increasing uterine 
action, but of alleviating the sufferings of childbirth. I have tried it 
in several cases, but am not satisfied as to its possessing the properties 
attributed to it. 

If we had no other means of increasing defective uterine contractions 
at our disposal, and if the choice lay only between the use of ergot aud 
instrumental delivery, there might not be so much objection to a cau- 
tious use of the drug in suitable cases. We have, however, a means of 
increasing the force of the uterine contractions so much more manage- 
able, and so much more resembling the natural process, that I believe 
it to be destined to entirely supersede the administration of ergot. 
This is the application of manual pressure to the uterus through the 
abdomen, an expedient that has of late years been much used in Ger- 
many, and has begun to be employed in English practice. I believe, 
therefore, that ergot should be chiefly used for the purpose of exciting 
uterine contraction after delivery, when its peculiar property of pro- 
moting tonic contraction is so valuable, and that it should rarely, if at 
all, be employed before the birth of the child. 

The systematic use of uterine pressure as an oxytocic was first promi- 
nently brought under the notice of the profession by Kristeller, under 
the name of expressio foetus, although it has been used in various 
forms from time immemorial. Albucasis, for example, was clearly 
acquainted with its use, and referred to it in the following terms : 
"Cum ergo vides ista signa tunc oportet, utcomprimatur uterus ejus ut 
descendat embryo velociter." It was known to Guillemeau, who says: 
"Quelquefois j'ai ordonne" a Fune des dites femmes de presser fort 
doucement du plat de la main, les parties superieures du ventre en 
ramenant P enfant, petit a petit, en bas ; telle mediocre compression 

1 Brit. Med. Journ., vol. ii. p. 689. 

2 Trans. Coll. Phys., Philadelphia, p. 183. 

3 Obst. Trans., vol. xxvi. p. 93. 



PROLONGED AND PRECIPITATE LABORS. 363 

faeilitait l'aecouchement en faisant que les tranchees se supportaient 
plus aisement et facilement. 1 There are some curious obstetric customs 
among various nations, which probably arose from a recognition of its 
value ; as, for example, the mode of delivery adopted among the Kal- 
mucks, where the patient sits at the foot of the bed, while a woman, 
seated behind her, seizes her around the waist and squeezes the uterus 
during the pains. Amongst the Japanese, Siamese, North American 
Indians, and many other nations, pressure, applied in various ways, is 
habitually used. 

Kristeller maintains that it is possible to effect the complete expul- 
sion of the child by properly applied pressure, even when the pains are 
entirely absent. Strange as this may appear to those who are not 
familiar with the effects of pressure, I believe that, under exceptional 
circumstances, when the pelvis is very capacious, and the soft parts 
offer but slight resistance, it can be done. I have delivered in this 
way a patient whose friends would not permit me to apply the forceps, 
when I could not recognize the existence of any uterine contraction at 
all, the foetus beiug literally squeezed out of the uterus. It is not, 
however, as replacing absent pains, but as a means of intensifying and 
prolonging the effects of deficient and feeble ones, that pressure finds 
its best application. 

Its effects are often very remarkable, especially in women of slight 
build, where there is but little adipose tissue in the abdominal walls, 
and not much resistance in the pelvic tissues. If the finger be placed 
on the head while pressure is applied to the uterus, a very marked 
descent can readily be felt, and not infrequently two or three applica- 
tions will force the head on to the perineum. There are, however, 
certain conditions in which it is inapplicable, and the existence of which 
should contra-indicate its use. Thus if the uterus seem unusually 
tender on pressure, and, a fortiori, if the tonic contraction of exhaus- 
tion be present, it is inadmissible. So also if there be any obstruction 
to rapid delivery, either from narrowing of the pelvis or rigidity of 
the soft parts, it should not be used. The cases suitable for its appli- 
cation are those in which the head or breech is in the pelvic cavity, 
and the delay is simply due to a want of sufficiently strong expulsive 
action. 

It may be applied in two ways. The better plan is to place the 
patient on her back at the edge of the bed, and spread the palms of 
the hands on either side of the fundus and body of the uterus, and, 
when a pain commences, to make firm pressure during its continuance 
downward and backward in the direction of the pelvic inlet. As the 
contraction passes off the pressure is relaxed, and again resumed when 
a fresh pain begins. In this way eaeli pain is greatly intensified, and 
its effect on the progress of the fret us much increased. It is not 
essential that the patient should lie on her back. A useful, although 
not so great, amount of pressure can be applied when she is lying in 
the ordinary obstetric position on her left side, the left hand being 
spread out over the fundus, leaving the right free to watch the progress 
of the presenting part per vaginam. 

i L'Obstetrique aux XVII et XVIII. Su-cles. Paris, 1S92. 



364 LABOR. 

Special Value of Uterine Pressure. — The special value of this 
method of treating ineffective pains is, that the amount and frequency 
of the pressure are completely within the control of the practitioner, 
and are capable of being regulated to a nicety in accordance with the 
requirements of each particular case. It has the peculiar advantage 
of closely imitating the natural means of delivery, and of being abso- 
lutely without risk to the child ; nor is there any reason to think that 
it is capable of injuring the mother. At least I may safely say that, 
out of the large number of cases in which I have used it, I have never 
seen one in which I had the least reason to think that it had proved 
hurtful. Of course, it is essential not to use undue roughness ; firm 
and even strong pressure may be employed, but that can be done 
without being rough, and, as its application is always intermittent, 
there is no time for it to inflict any injury on the uterine tissues. 

Pressure is specially valuable when it is desirable to intensify 
feeble pains. It may be serviceably employed when the pains are 
altogether absent, to imitate and replace them, provided there be 
nothing but the absence of a vis a tergo to prevent speedy delivery. 
In such cases an endeavor should be made to imitate the pains as 
closely as possible, by applying the pressure at intervals of four or five 
minutes, and entirely relaxing it after it has been applied for a few 
seconds. 

Instrumental Delivery. — When all these means fail we have then 
left the resource of instrumental aid, and we have now to consider the 
indications for the use of the forceps under such circumstances. It 
has been already pointed out that professional opinion on this point 
has been undergoing a marked change ; and that it is now recognized 
as an axiom by the most experienced teachers that, when we are once 
convinced that the natural efforts are failing, and are unlikely to effect 
delivery, except at the cost of long delay, it is far better to interfere 
soon rather than late, and thus prevent the occurrence of the serious 
symptoms accompanying protracted labor. The recent important 
debate on the use of the forceps at the Obstetrical Society of London 
remarkably illustrated these statements, for while there was much 
difference of opinion as to the advisability of applying the forceps 
when the head was high in the pelvis, a class of cases not now under 
consideration, it was very generally admitted that the modern teaching 
was based on correct scientific grounds. This is, of course, directly 
opposed to the view so long taught in our standard works, in which 
instrumental interference was strictly prohibited unless all hope of 
natural delivery was at an end ; and in which the commencement at 
least, if not the complete establishment, of symptoms of exhaustion, 
was considered to be the only justification for the application of the 
forceps in lingering labor. 

The reasous which led the late distinguished master of the Rotunda 
Hospital to a more frequent use of the forceps are so well expressed in 
his report for 1872, that I venture to quote them as the best justifica- 
tion for a practice that many practitioners of the older school will, no 
doubt, be inclined to condemn as rash and hazardous. He says: 1 "Our 

i Fourth Clinical Report of the Rotunda Lying-in Hospital. 



PROLONGED AND PRECIPITATE LABORS. 365 

established rule is that so long as Nature is able to effect its purpose 
without prejudice to the constitution of the patient, danger to the soft 
parts, or the life of the child, we are in duty bound to allow the labor 
to proceed ; but as soon as we find the natural efforts are beginning to 
fail, and after having tried the milder means for relaxing the parts or 
stimulating the uterus to increased action, and the desired effects not 
being produced, we consider we are in duty bound to adopt still 
prompter measures, and by our timely assistance . relieve the sufferer 
from her distress and her offspring from an imminent death. Why, 
may I ask, should we permit a fellow-creature to undergo hours of 
torture when we have the means of relieving her within our reach ? 
Why should she be allowed to waste her strength, and incur the risks 
consequent upon long pressure of the head on the soft parts, the ten- 
dency to inflammation and sloughing, or the danger of rupture, not to 
speak of the poisonous miasma which emanates from an inflammatory 
state of the passages, the result of tedious labor, and which is one of 
the fertile causes of puerperal fever and all its direful effects, attributed 
by some to the influence of being confined in a large maternity, and 
not to its proper source, i. e., the labor being allowed to continue till 
inflammatory symptoms appear ? The more we consider the benefits 
of timely interference, and the good results which follow it, the more 
are we induced to pursue the system we have adopted, and to inculcate 
to those we arc instructing the advantages to be gained by such practice, 
both in saving the life of the child as well as securing the greater safety 
of the mother.' 7 It would be impossible to put the matter in a stronger 
or clearer light, and I feel confident that these views will be indorsed 
by all who have adopted the more modern practice. 

Effect of Early Interference on the Infantile Mortality. — In the 
first edition of this work I used the statistics of Dr. Hamilton, of 
Falkirk, and other modern writers, as proving that a more frequent 
use of the forceps than had been customary diminished in a remarkable 
degree the infantile mortality. Dr. Galabin 1 has recently published an 
admirable paper on this subject, in which, by a careful criticism of 
these figures, he has, I think, proved that the conclusions drawn from 
them are open to doubt, and that the saving of infantile life following 
more frequent forceps delivery is by no means so great as I had sup- 
posed. Dr. Roper, in his remarks in the recent debate in the Obstet- 
rical Society, already alluded to, brought forward some strong argu- 
ments in support of the same view. This, however, does not in any way 
touch the main points at issue referred to in the preceding paragraph. 

Possible Dangers attending- the Use of the Forceps. — It is, of 
course, right that we should consider the opposite point of view, and 
reflect on the disadvantages which may attend the interference advo- 
cated. Here I should point out that I am now writing only of the use 
of the forceps in simple inertia, when the head is low in the pelvic 
cavity, and when all that is wanted is a slight vis afronte to supplement 
the deficient vis a tergo. The use of the instrument when the head is 
arrested high in the pelvis, or in cases of deformity, or before the os 

1 Obstet. Journ., vol. v. p. 561. 



366 LABOR. 

uteri is completely expanded, is an entirely different and much more 
serious matter, and does not enter into the present discussion. The 
chief question to decide is, if there be sufficient risk to the mother to 
counterbalance that of delay. It will, of course, be conceded by all 
that the forceps in the hands of a coarse, bungling, and ignorant prac- 
titioner, who has not studied the proper mode of operating, may easily 
inflict serious damage. The possibility of inflicting injury in this way 
should act as a warning to every obstetrician to make himself thor- 
oughly acquainted with the proper mode of using the instrument, and 
to acquire the manual skill which practice and the study of the 
mechanism of delivery will alone give; but it is not a valid argument 
against its proper use. If that were admitted, surgical interference of 
any kind would be tabooed, since there is none that ignorance and in- 
capacity might not render dangerous. 

Assuming, therefore, that the practitioner is able to apply the forceps 
skilfully, is there any inherent clanger in its use ? I think all who 
dispassionately consider the question must admit that, in the class of 
cases alluded to, the operation is so simple that its disadvantages can- 
not for a moment be weighed against those attending protraction and 
its consequences. Against this conclusion statistics may possibly be 
quoted, such as those of Churchill, who estimated that one in twenty 
mothers delivered by forceps in British practice was lost. But 
the fallacy of such figures is apparent on the slightest consideration ; 
and by no one has this been more conclusively shown than by Drs. 
Hicks and Phillips in their paper on tables of mortality after obstetric 
operations, 1 where it is proved in the clearest manner that such results 
are clue not to the treatment, but rather to the fact that the treatment 
was so long delayed. 

It is quite impossible to lay clown any precise rale as to when the 
forceps should be used in uterine inertia. Each case must be treated 
on its own merits, and after a careful estimate of the effects of the 
pains. The rules generally taught were that the head should be 
allowed to rest at or near the perineum for a number of hours, and 
that interference was contra-indicated if the slightest progress were 
being made. It is needless to say that both of these rules are incom- 
patible with the views I have been inculcating, and that any rule 
based upon the length of time the second stage of labor has lasted 
must necessarily be misleading. What has to be done, I conceive, is 
to watch the progress of the case anxiously after the second stage has 
fairly commenced, and to be guided by an estimate of the advance that 
is being made and the character of the pains, bearing in mind that the 
risk to the mother, and still more to the child, increases seriously with 
each hour that elapses. If we find the progress slow and unsatisfac- 
tory, the pains flagging and insufficient, and incapable of being 
intensified by the means indicated, then, provided the head be low in 
the pelvis, it is better to assist at once by the forceps, rather than to 
wait until we are driven to do so by the state of the patient. 2 

1 Obst Trans., vol. xiii. p. 55. 

- It may, perhaps, be of interest in connection with this important topic in practical midwifery 
if I reprint a letter I published some years ago in the Medical Times and Gazette. An historical 



PROLONGED AND PRECIPITATE LABORS. 367 

Precipitate Labor Less Common than Lingering. — Undue 
rapidity of labor is certainly more uncommon than its converse, but 

case, such as that of which it treats, will better illustrate the evil effects that may follow un- 
necessary delay than any amount of argument. It seems to me impossible to read the details of 
the delivery it describes without being forcibly struck with the disastrous results which followed 
the practice adopted, which, however, was strictly in accordance with that considered correct, 
up to a quite recent date, by the highest obstetric authorities. 

Ok the Death of the Princess Charlotte of Wales. 
(To the Editor of the Medical Times and Gazette.) 

Sir: The letter of your correspondent, "An Old Accoucheur," regarding the death of the 
Princess Charlotte, raises a question of great interest— viz., whether the fatal result might have 
been averted under other treatment? The history of the case is most instructive, and I think a 
careful consideration of it leaves little room to doubt that, though the management of the labor 
was quite in accordance with the teaching of the day, it was entirely opposed to that of modern 
obstetric science. The following account of the labor may interest your readers, and will probably 
be new to most of them. It is contained in a letter from Dr. John Sims to the late Dr. Joseph 
Clarke, of Dublin : 

" London, November 15, 1817. 

"My dear Sir : I do not wonder at your wishing to have a direct statement of the labor of her 
Royal Highness the Princess Charlotte", the fatal issue of which has involved the whole nation in 
distress. You must excuse my being very concise, as I have been, and am, very much hurried. 
I take the opportunity of writing this in a lying-in chamber. Her Royal Highness's labor com- 
menced by the discharge of the liquor amnii about seven o'clock on Monday evening, and the 
pains followed soon after. They continued through the night and a greater part of the next day — 
sharp, soft, but very ineffectual. Toward the evening Sir Richard Croft began to suspect that 
labor might not terminate without artificial assistance, and a message was despatched for me. 
I arrived at two on Wednesday morning. The labor was now advancing more favorably, and 
both Dr. Baillie and myself concurred in the opinion that it would not be advisable to inform her 
Royal Highness of my arrival. From this time to the end of her labor the progress was uniform, 
though very slow, the patient in good spirits, the pulse calm, and there never was room to enter- 
tain a question about the use of instruments. About six in the afternoon the discharge became 
of a green color, which led to a suspicion that the child might be dead ; still the giving assistance 
was quite out of the question, as the pains now became more effectual, and the labor proceeded 
regularly, though slowly. The child was born without artificial assistance at nine o'clock in the 
evening! Attempts were made for a good while to reanimate it by inflating the lungs, friction, 
hot baths, etc.. but without effect; the heart could not be made to beat even once. Soon after 
delivery. Sir Richard Croft discovered that the uterus was contracted in the middle in the hour- 
glass form, and as some hemorrhage commenced it was agreed that the placenta should be 
brought away by introducing the hand. This was done about half an hour after the delivery of 
the child, with more ease and less blood than usual. Her Royal Highness continued well for 
about two hours ; she then complained of being sick at stomach, and of noise in the ears, began 
to be talkative, and her pulse became frequent ; but I understand she was very quiet after this, 
and her pulse calm. About half-past twelve o'clock she complained of severe pain in the chest, 
became extremely restless, with rapid, weak, and irregular pulse. At this time I saw her for the 
first time. It has been said that we had all gone to bed, but that is not a fact ; Croft did not leave 
her room, Baillie retired about eleven, and I went to my bedchamber and laid down in my clothes 
at twelve. By dissection, some bloody fluid (two ounces) was found in the pericardium, supposed 
to be thrown out in articulo mortis. The brain and other organs all sound, except the right 
ovarium, which was distended into a cyst the size of a hen's egg. The hour-glass contraction of 
the uterus still visible, and a considerable quantity of blood in the cavity of the uterus— but those 
present dispute about the quantity, so much as from twelve ounces to a pound and a half— her 
uterus extending as high as her navel. The cause of her Royal Highness's death is certainly 
somewhat obscure ; the symptoms were such as attend death Irom hemorrhage, but the loss of 
blood did not seem to be* sufficient to account for a fatal issue. It is possible that the effusion 
into the pericardium took place earlier than was supposed, and it does not seem to be quite cer- 
tain that this might not be the cause. That I did not see her Royal Highness more early was awk- 
ward, and it would have been better that I had been introduced before the labor was expected ; 
and it should have been understood that when labor came on I should be sent to without waiting 
to know whether a consultation was necessary or not. I thought so at the time, but I could not 
propose such an arrangement to Croft. But this is entirely entre nous. I am glad to hear that 
your son is well, and with all my family, wish to be remembered to him. We were happy to 
hear that he was agreeably married. 

" I remain, my dear Doctor, 

"Ever yours most truly, 

"John" Sims, M.D. 

" This letter is confidential, as perhaps I might be blamed for writing any particulars without 
the permission of Prince Leopold." 

What are the facts here shown? Here was a delicate young woman, prepared for the trial before 
her. as Baron stockmar tells us. by " lowering the organic strength of the mother by bleeding, 
aperients, and low diet." who was allowed to go on in lingering feeble labor for no le.-s than fifty 
hours after the escape of the liquor amnii ! Such was the groundless dread of instrumental inter- 
ference then prevalent that, although the case dragged on its weary length with feeble, ineffectual 
pains, every now and then increasing in intensity and then falling off again, it is stated " there 
never was foora to entertain a question about the use of instruments " ; and even " when the dis- 
charge became of a green color stdl the giving assistance was quite out of the question " .' 

Can anv reasonable man doubt that if the force] >s had been employed hours and hours before— 
say on Tuesdav, when the pains fell off— the result would probably have been very different, and 
that the life of the child, destroyed by the enormously prolonged second staize, would have been 
saved? It must be remembered that early on Tuesday morning delivery was expected, so that 
the head must then have been low in the pelvis [vide Stockmar's Memoirs, vol. i. p. 63). It would 
be difficult to find a case which more forcibly illustrates the danger of delay in the second stage 



368 



LABOR 



still it is by no means of unfrequent occurrence. Most obstetric 
works contain a formidable catalogue of evils that may attend it, each 

of labor. Then what follows? The uterus, exhausted by the lengthy efforts it should have been 
spared, fails to contract effectually; nor do we hear of any attempts to produce contraction by 
pressure. The relaxed organ becomes full of clots, extending up to the umbilicus, and all the 
most characteristic symptoms ot concealed post-partum hemorrhage develop themselves She 
complained "of being sick at stomach, and of noise in her ears, began to be talkative, and her 
pulse became frequent." Before long other symptoms came on, graphically described 'by Baron 
Stockmar, and which seem to point to the formation of a clot in the heart and pulmonary arte- 
ries—a most likely occurrence after such a history. " Baillie sent mo word that he wished me to 
see the Princess. I hesitated, but at last went with him. She was suffering from spasms of the 
chest and difficulty of breathing, in great pain, and very restless, and threw herself continually 
from one side of the bed to the other, speaking now to Baillie, now to Croft. Baillie said to her 
' Here comes an old friend of yours.' She held out her left hand to me, hastily, and pressed mine 
warmly twice. I felt her pulse ; it was going very fast— the beats now strong, now feeble, now 
intermittent." 

Here was evidently something different from the exhaustion of hemorrhage ; and no one who 
has witnessed a case of pulmonary obstruction can fail to recognize in this account an accurate 
delineation of its dreadful symptoms. Surely this lamentable story can only lead to the conclu- 
sion that the unhappy and gifted Princess fell a victim to the dread of that bugbear " meddle- 
some midwifery," which has so long retarded the progress of obstetrics. 

„ „ „ „„ „ I am, etc., W. S. Playfaib. 

Cubzon Stbeet, Mayfaib, W., November 29, 1872. 

The views as to the treatment of prolonged labor here enunciated have been so generally received 
with favor by the profession, that there has hitherto been no reason to defend them. Recently, 
however, Professor W. Japp Sinclair, of Manchester, in his address to the British Medical Associa- 
tion at Montreal,* has brought a strong indictment against both the teaching and the practice of 
the present day. 

In this he says: "The thesis I shall endeavor to maintain is that gynecology has become so 
largely surgical as the direct result of surgical interference in midwifery practice ; the accoucheurs 
are the providers of material for the gynecologist." This sentence surely cannot be seriously 
meant I was under the impression that the large development of surgical gynecology witnessed 
during the last twenty or thirty years is due to such matters as the surgical treatment of fibro- 
myomata, ovariotomy, an increased knowledge of diseases of the appendages and the like, and it 
is difficult to understand how the accoucheurs can be taken to provide work of this kind for their 
gynecological colleagues. But let us pass the sentence as a harmless exaggeration, and consider 
what is really meant. 

I am quite willing to admit that the improved midwifery practice of the last quarter of a cen- 
tury has often led to great abuse in the hands of men who have had neither the judgment nor the 
practical skill to carry it out properly. 

This is unfortunately the case with all improvements in medicine. Take the very operation 
which Dr. Sinclair refers to as required to remedy the evils produced by the forceps, with regard 
to which he quotes Jenks as saying of it that it is " one of the greatest advances in modern gyne- 
cology," adding, from himself, "an opinion not so generally held in England as it ought to be." 
This I quite agree with ; but who that knows the history of tracheloraphe is not aware of the mon- 
strous and almost ludicrous errors into which the enthusiasm of its advocates led them, and on 
account of which the operation has been looked on with suspicion and disfavor in this country? 
So with many other really great advances in medicine, such as the removal of the uterine appen- 
dages, the "rest cure" in neuroses, and the latest fashion, the "Schott treatment" in heart dis- 
ease. Of all these it may be said that the abuse of a good thing is no argument against its use ; 
and so it is with the more frequent application of the forceps. 

I should have been content to agree with much that Professor Sinclair says did he not go far 
beyond warning, and speak with misleading approval of the old and bad rules of practice recom- 
mended by Collins and his contemporaries. On this point it is my duty to speak plainly, not only 
as a teacher, but as the author of a treatise which the profession has done me the honor to use 
largely. 

Now to take first one of Dr. Sinclair's great points— the injuries resulting from the use of the 
forceps. He assumes that practieally all cases of lacerated cervix and ruptured perineum are the 
result of injudicious use of the forceps. Surely these injuries were met with often enough in the 
good old days Professor Sinclair so much regrets, the latter being left unrepaired, the former un- 
recognized? Is it not a fact that a thin, tense, and overstretched cervix will yield to the vis d tergo 
of a head forced down upon it? Where, again, is the evidence that the application of the forceps 
within an undilated cervix is as common as Dr. Sinclair supposes? For my part, I entirely dis- 
believe that so rash and hazardous a practice can be resorted to with anything like the frequency 
he assumes; and certainly it is not taught either in this or in any other text-book known to me. 
I have fairly good opportunities of noting the lesions referred to, and I certainly have not come 
across them with anything in the least approaching the frequency Dr. Sinclair seems to find in 
Manchester. 

As against the lesions found in modern practice, one might very fairly put those produced by the 
practice prevalent in the time of Collins. In my student days vesico-vaginal fistula was an every- 
day thing. Now, I venture to say, a student may pass through his whole curriculum without ever 
having seen a case. Why is this? Simply that they are not made. If there is one fact in mid- 
wifery more certain than another, it is that vesico-vaginal fistulse are not usually the results of 
laceration by the forceps, but, in the vast majority of cases, of pressure and contusion from long 
delay of the head in one position. 

Again, Dr. Sinclair says nothing of the all-important fact that in modern practice craniotomy is 
happily reduced to a minimum. Many of us go vears without seeing a case. During Dr. Collins's 
Mastership, craniotomy was performed once in 207 cases ; during Dr. Johnston's, once in 289. By 
a simple rule-oi-three sum it will be seen that 23 lives were presumably saved by Dr. Johnston 
which w r ould have been sacrificed under his predecessor. I cannot agree with Professor Sinclair 
that all lacerated cervices and perinea are caused by forceps ; but, even admitting his assumption 

* Brit. Med. Journ., September 4, 1897. 



PROLONGED AND PRECIPITATE LABORS. 369 

as rupture of the cervix, or even of the uterus itself, from violence of the 
uterine action ; laceration of the perineum from the presenting part 
being driven through before dilatation has occurred ; fainting from 
the sudden emptying of the uterus ; hemorrhage from the same cause. 
With regard to the child it is held that the pressure to which it is 
subjected, and sudden expulsion while the mother is in the erect posi- 
tion, may prove injurious. Without denying that these results may 
possibly occur now and again, in the majority of cases over-rapid 
labor is not attended with any evil effects. 

Precipitate labor may generally be traced to one of two conditions, 
or to a combination of Doth ; excessive force and rapidity of the pains, 
or unusual laxity and want of resistance of the soft parts. The pre- 
cise causes inducing these it is difficult to estimate. In some cases the 
former may depend on an undue amount of nervous excitability, and 
the latter on the constitutional state of the patient tending to relaxa- 
tion of the tissues. 

Whatever the cause, the extreme rapidity of labor is occasionally 
remarkable, and one strong pain may be sufficient to effect the expul- 
sion of the child with little or no preliminary warning. I have known 
a child to be expelled into the pan of a water-closet, the only previous 
indication of commencing labor being a slight griping pain, which led 
the mother to fancy that an action of the bowels was about to take 
place. More often there is what may be described as a storm of uterine 
contractions, one pain following the other with great intensity, until 
the foetus is expelled. The natural effect of this is to produce a great 
amount of alarm or nervous excitement, which of itself forms one of 
the worst results of this class of labor. It is under such circumstances 
that temporary mania occurs, produced by the intensity of the suffering, 
under which the patient may commit acts, her responsibility for which 
may fairly be open to question. 

Little Treatment Possible. — Little can be done in treating undue 
rapidity of labor. We can, to some extent, modify the intensity of the 
pains by urging the patient to refrain from voluntary efforts, and to 
open the glottis by crying out, so that the chest may no longer be a 
fixed point for muscular action. Opiates have been advised to control 
uterine action, but it is needless to point out that, in most cases, there 
is no time for them to take effect. Chloroform will often be found 
most valuable, from the rapidity with which it can be exhibited ; and 
its power of diminishing uterine action, which forms one of its chief 
drawbacks in ordinary practice, will here prove of much service. 

by wav of argument, I wonder how many cases of such accidents might be fairly taken as out- 
weighing even a single human life saved from the deadly perforator? Even such a laudator tem- 
poris acti as Dr. Sinclair would hardly venture to compare the two. 

I willingly admit that Dr. Sinclair's address will do good. It is to be hoped that it will moderate 
such injudicious practice as he condemns, as every judicious practitioner would. But I cannot 
admit that this is the result of modern text-books or modern teaching. I think that a perusal of 
what has been written in the preceding chapter, which stands as it did in former editions, does not 
justify such an accusation, and that I have carefully safeguarded the opinions given, and warned 
against any kind of error. 

24 



370 LABOR. 



CHAPTEE X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE 
SOFT PARTS. 

Rigidity of the Cervix a Frequent Cause of Protracted Labor. 
- — One of the most frequent causes of delay in the first stage of labor 
is rigidity of the cervix uteri, which may depend on a variety of con- 
ditions. It is often produced by premature escape of the liquor amnii, 
in consequence of which the fluid wedge, which is Nature's means of 
dilating the os, is destroyed, and the hard presenting part is conse- 
quently brought to bear directly upon the tissues of the cervix, which, 
are thus unduly irritated, and thrown into a state of spasmodic con- 
traction. At other times it may be due to constitutional peculiarities, 
among which there is none so common as a highly nervous and emo- 
tional temperament, which renders the patient peculiarly sensitive to- 
ner sufferings, and interferes with the harmonious action of the uterine 
fibres. The pains, in such cases, cause intense agony, are short and 
cramp-like in character, but have little or no effect in producing dila- 
tation ; the os often remaining for many hours without any appreciable 
alteration, its edges being thin and tightly stretched over the head. 
Less often, and this is generally met with in stout, plethoric women, 
the edges of the os are thick and tough. 

The effects of prolongation of labor from this cause will vary much 
under different circumstances. If the liquor amnii be prematurely 
evacuated, the presenting part presses directly upon the cervix, and 
the case is then practically the same as if the labor was in the second 
stage. Hence grave symptoms may soon develop themselves, and 
early interference may be imperatively demanded. If the membranes 
be unruptured, delay will be of comparatively little moment, and con- 
siderable time may elapse without serious detriment to either the 
mother or child. 

The treatment will naturally vary much with the cause and the 
state of the patient. In the majority of cases, especially if the mem- 
branes be intact, patience and time are sufficient to overcome the ob- 
stacle ; but it is often in the power of the accoucheur materially to aid 
dilatation by appropriate management. Sometimes Nature overcomes 
the obstruction by lacerating the opposing structures ; and cases are on 
record in which even a complete ring of the cervix has been torn off 
and come away before the head. 

Many remedies have been recommended for facilitating dilatation, 
some of which no doubt act beneficially. Among those most fre- 
quently resorted to was venesection, and with it was generally asso- 
ciated the administration of nauseating doses of tartar emetic. Both 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 371 

these acted by producing temporary depression, under which the 
resistance of the soft parts was lessened. They probably answer best 
in cases in which there was a rigid and tough cervix ; and they might 
prove serviceable, even yet, in stout, plethoric women of robust frame. 
Practically they are now seldom, if ever, employed, and other and less 
debilitating remedies are preferred. The agent, par excellence, most 
serviceable is chloral, which is of special value in the more common 
cases in which rigidity is associated with spasmodic contraction of the 
muscular fibres of the cervix. Two or three doses of fifteen grains, 
repeated at intervals of twenty minutes, are often of almost magical 
efficacy, the pains becoming steady and regular, and the os gradually 
relaxing sufficiently to allow the passage of the head. Should the 
chloral be rejected by the stomach, it may be satisfactorily adminis- 
tered per rectum. Chloroform acts much in the same way, but on the 
whole less satisfactorily, its effects being often too great ; while the 
peculiar value of chloral is its influence in promoting relaxation of the 
tissues, without interfering with the strength of the pains. 

Various local means of treatment may be also advantageously used. 
One is the warm bath, which is much used in France. It is of un- 
questionable value where there is mere rigidity, and may be used either 
as an entire bath, or as a hip-bath, in which the patient sits from 
twenty minutes to half an hour. The objection is the fuss and excite- 
ment it causes, and, for this reason, it is an expedient seldom resorted 
to in this country. A similar effect is produced, and much more easily, 
by a douche of tepid water upon the cervix. This can be very easily 
administered, the pipe of a Higginson's syringe being guided up to the 
cervix by the index finger of the right hand, and a stream of water 
projected against it for five or ten minutes. Smearing the os with 
extract of belladonna is advised by Continental authorities, but its 
effects are more than doubtful. Horton 1 advocates the injection into 
the tissue of the cervix of -j-$ of a grain of atropine by means of a hypo- 
dermatic syringe. Professor Simpson 2 speaks very favorably of the 
good results following the injection of an ounce of glycerine between the 
membranes and the lower uterine segment, an adaptation of the method 
recommended by Pelzer for the induction of premature labor. 

Artificial Dilatation. — Artificial dilatation of the cervix by the 
finger has often been recommended, and has been the subject of much 
discussion, especially in the Edinburgh school, where it was formerly 
commonly employed. It is capable of being very useful, but it may 
also do much injury when roughly and injudiciously used. The class 
of cases in which it is most serviceable are those in which the liquor 
amnii has been long evacuated, and in which the head, covered by the 
tightly stretched cervix, has descended low into the pelvic cavity. 
Under these circumstances, if the finger be passed gently within the os 
daring a pain, and its margin pressed upward and over the head, as it 
were, while the contraction lasts, the progress of the case may be mate- 
rially facilitated. This manoeuvre is somewhat similar to that which 
has been already spoken of, when the anterior lip of the cervix is 

: Amer. Journ. of Obstet., vol. xi p. 482. 
2 Edin. Obstet. Traus , vol. xviii. p. 98. 



372 LABOR. 

caught between the head and the pubic bone, and, if properly per- 
formed, I believe it to be quite safe, and often of great value. It is 
not, however, well adapted for those cases in which the membranes 
are still intact, or in which the os remains undilated when the head is 
still high in the pelvis. When there is much delay under these con- 
ditions, and interference of some kind seems called for, the dilatation 
may be much assisted by the use of caoutchouc dilators, described in 
the chapter on the induction of premature labor, which imitate Nature's 
method of opening up the os, and also act as a direct stimulant to 
uterine contraction. But it should be remembered that it is precisely 
in such cases that delay is least prejudicial. If, however, the os be 
excessively long in opening, its dilatation may be safely and efficiently 
promoted by passing within it, and distending with water, one of the 
smallest-sized bags ; and, after this has been in position from ten to 
twenty minutes, it may be removed, and a larger one substituted. 
Champetier de Ribes' bag may be used for the same purpose, if pre- 
ferred. 

Rigidity depending 1 upon Organic Causes. — Every now and 
again we meet with cases in which the obstacle depends upon organic 
changes in the cervix, the most common of which are cicatricial hard- 
ening from former lacerations ; hypertrophic elongation of the cervix 
from disease antecedent to pregnancy; or even agglutination and 
closure of the os uteri. Cicatrices are generally the result of lacerations 
during former labors. They implicate a portion only of the cervix, 
which they render hard, rigid, and undilatable, while the remainder 
has its natural softness. They can readily be made out by the exam- 
ining finger. A somewhat similar, but much more formidable, obstruc- 
tion is occasionally met with in cases of old-standing hypertrophic 
elongation of the cervix, which is generally associated with prolapse. 
In most cases of this kind the cervix becomes softened during preg- 
nancy, so that dilatation occurs without any unusual difficulty. But 
this does not always happen. A good example is related by Mr. 
Roper, in the seventh volume of the Obstetrical Transactions (p. 233), 
in which such a cervix formed an almost insuperable obstacle to the 
passage of the child. 

Carcinoma of the cervix uteri, which produces extensive thickening 
and induration of its tissues, and even advanced malignant disease of 
the uterus, is no bar to conception. The relations of malignant disease 
to pregnancy and parturition have recently been well studied by Dr. 
Herman. 1 He concludes that cancer renders the patient inapt to con- 
ceive, but that when pregnancy does occur there is a tendency to the 
intra-uterine death and premature expulsion of the foetus, and the 
growth of the cancer is accelerated. When delivery is accomplished 
naturally there is generally expansion of the cervix by Assuring of its 
tissue, but the harder forms of cancer may form an insuperable obstacle 
to delivery. 

Agglutination of the margins of the os uteri is occasionally met 
with, and must, of course, have occurred after conception. It is 

1 Obst, Trans., vol. xx. p. 191. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 373 

generally the result of some inflammatory affection of the cervix during 
the early months of gestation ; and I have known it recur in the same 
woman in two successive pregnancies. Usually it is not associated 
with any hardness or rigidity, but the entire cervix is stretched over 
the presenting part, and forms a smooth covering, in which the os may 
only exist as a small dimple, and may be very difficult to detect at all. 
Occlusion of the os uteri from inflammatory change sometimes so 
alters the cervix that no sign of the original opening can be dis- 
covered ; and in two such instances the Cesarean operation has been 
performed in the United States, by w T hich the women were saved. 1 

Their Treatment. — Any of these mechanical causes of rigidity may 
at first be treated in the same way as the more simple cases ; and with 
patience, the use of chloral and chloroform, and of the fluid dilators, 
sufficient expansion to permit the passage of the head will often take 
place. But if these methods produce no effect, and symptoms of con- 
stitutional irritation are beginning to develop themselves, other and 
more radical means of overcoming the obstruction may be required. 

Under such circumstances incision of the cervix may be not only 
justifiable but essential, and it frequently answers extremely well. On 
the Continent it is resorted to much more frequently and earlier than 
in this country, and with the most beneficial results. The operation 
offers no difficulties. The simplest way of performing it is to guard 
the greater portion of the blade of a straight blunt-pointed bistoury by 
wrapping lint or adhesive plaster around it, leaving about half an inch 
of cutting edge toward its point. This is guided to the cervix, on the 
under surface of the index finger, and three or four notches are cut in 
the circumference of the os to about the depth of a quarter of an inch. 
Very generally, especially when the obstruction is only due to old 
cicatrices, the pains will now T speedily effect complete expansion, which 
may be very advantageously aided by applying the hydrostatic dilators. 
When the obstruction is due to carcinomatous infiltration or inflam- 
matory thickening, the case is much more complicated, and will pain- 
fully tax the resources of the accoucheur. If it is possible, the disease 
should be removed as much as can be safely done during pregnancy, 
which should also be brought to an end before the full period. During 
labor, incisions should form a preliminary to any subsequent proceed- 
ings that may be necessary, as they are, at the worst, not likely to 
increase in the least the risk the patient has to run, and they may 
possibly avert more serious operations. In the case of malignant 
disease the risk of serious hemorrhage, from the great vascularity of 
the tissues, must not be forgotten, and, if necessary, means must be 
taken to check this by local styptics, such as perchloride of iron. If 
incision fail, and the state of the patient demands speedy delivery, the 
forceps may be applied, and Herman thinks they are, as a rule, better 
than turning. He also maintains that there is little difference in the 
risk to the mothers between craniotomy and the Cesarean section, and 
that the possibility of saving the child in cases in which incisions have 
failed should induce us to prefer the latter. If the Cesarean section is 

1 Harris's note to second American edition. 



374 LABOR. 

required, and the disease is limited to the uterus, it is possible that the 
mother's life might be saved by following the delivery of the child by 
pan-hysterectomy. It was my intention to adopt this procedure in a 
case I lately saw, in which I thought it would not be possible to effect 
delivery per vias nat urates. Unfortunately, as I now think, for the 
mother, I succeeded iu delivering the child with the forceps, at the 
expeuse of a good deal of cervical laceration. At the time the malig- 
nant disease was entirely confined to the cervix. Six weeks afterward, 
when I again saw the patient, with the view of performing vaginal 
extirpation of the uterus, the disease had extended to the roof of the 
vagina, so that no operative procedure was then possible. 

Application of the Forceps within the Cervix. — Before per- 
forming craniotomy, when the os is sufficiently open, a cautious appli- 
cation of the forceps is quite justifiable. Steady and careful downward 
traction, combined with digital expansion, has often enabled a head to 
pass with safety through an os that has resisted all other means of 
dilatation, and the destruction of the child has thus been avoided. 
If, indeed, the os appear to be dilatable, this procedure may advan- 
tageously be adopted before incision, and, as a matter of fact, it is 
commonly practised in the Rotunda Hospital. An operation involv- 
ing, beyond doubt, of itself some risk, and requiring considerable 
operative dexterity, would naturally not be lightly and inconsiderately 
undertaken. But when it is remembered that the alternative is the 
destruction of the child, the risk of exhaustion, and at least as great 
mechanical injury to the mother, its difficulty need not stand in the 
way of its adoption. 

Treatment when Occlusion of the Os exists. — When the os is 
apparently obliterated, incision is the only resource. Before resorting 
to it the patient should be placed under chloroform, and the entire 
lower segment of the uterus carefully explored. Possibly the aperture 
may be found high up, and out of reach of an ordinary examination, 
or we may detect a depression corresponding to its site. A small 
crucial incision may then be made at the site of the os, if this can be 
ascertained ; if not, at the most prominent portion of the cervix. Very 
generally the pains will then suffice to complete expansion, which may 
be further aided by the fluid dilators. 

Ante-partum Hour-glass Contraction. — Dr. Hosmer 1 has drawn 
attention to a hitherto undescribed species of dystocia, which he terms 
" ante-partum hour-glass contract Ion/ 7 and which he believes to depend 
on constriction of the uterine fibres at the site of the internal os uteri. 
Dr. Blundell refers to it in his work on obstetrics (1840) under the 
title of "Circular Contraction of the Middle of the Womb." Harris 2 
doubts its limitation to the internal os uteri, and terms it "tetanoid 
falciform constriction of the uterus'' AVhatever its site, in the cases 
recorded difficulties of the most formidable kind arose from this cause. 
The pelves were normal and the presentations natural, yet out of seven 
labors four ended fatally, two before delivery. The constriction seems 
to have grasped the foetus with such force as to have rendered extraction, 

1 Boston Med. and Surg. Journ., 1878, March and May. 

2 Harris's note to second American edition. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 375 

either by the forceps or turning, impossible. I have no personal ex- 
perience of this complication, which must fortunately be very rare. 
The introduction of the hand, the patient being deeply anaesthetized, 
would probably render diagnosis easy. The treatment must depend 
on the force and amount of constriction. If the constriction does not 
relax under chloroform, chloral, or the injection of atropine into the 
site of constriction, as recommended by Horton in rigidity of the 
cervix, turning would probably be our best resource. Should this fail, 
the Cesarean section may be required to eifect delivery, as happened in 
a case recorded by Dr. T. A. Foster, of Portland, Maine. 

Bands and Cicatrices in the Vagina. — Extreme rigidity of the 
vagina, or bands and cicatrices in or across its walls, the result of con- 
genital malformation, of injuries in former labors, or of antecedent 
disease, occasionally obstruct the second stage. There is seldom any 
really formidable difficulty from this cause, since the obstruction almost 
always yields to the pressure of the presenting part. If there be any 
considerable extent of cicatrices in the vagina, artificial assistance may 
be required. If we should be aware of their existence during preg- 
nancy, and find them to be sufficiently dense and extensive to be likely 
to interfere with delivery, an endeavor may be made to dilate them 
gradually by hydrostatic bags or bougies. If they be not detected 
until labor is in progress, we must be guided in our procedure by the 
pressure to which they are subjected. It may then be necessary to 
divide them with a knife, and to hasten the passage of the head by the 
forceps, so as to prevent contusion as much as possible. It is obvi- 
ously impossible to lay down any positive rules for such rare contin- 
gencies, the treatment suitable for which must necessarily vary much 
with the individual peculiarities of the case. 

Extreme Rigidity of the Perineum. — Extreme rigidity of the 
perineum is often dependent upon cicatricial hardening from injury in 
previous labors. This may greatly interfere with its dilatation ; and 
if laceration seems inevitable, we may be quite justified in attempting 
to avert it by incision of the margins of the perineum, on the principle 
of a clean cut being always preferable to a jagged tear. 

Labor complicated with Tumor. — Occasionally we meet with very 
formidable obstacles from tumors connected with the maternal struc- 
tures. These are most commonly either fibroid or ovarian, although 
others may be met with, such as malignant growths from the pelvic 
bones, exostoses, etc. 

Considering the frequency with which women suffer from fibroid 
tumors of the uterus, it is perhaps somewhat remarkable that these do 
not more often complicate delivery. Probably women so affected are 
not apt to conceive. Occasionally, however, cases of this kind cause 
much anxiety. Of course, those cases are most grave in which tumors 
are so situated as to encroach upon the cavity of the pelvis and me- 
chanically obstruct the passage of the child. Even those in which this 
does not occur are by no means free from danger, for interstitial and 
sub-peritoneal fibroids, situated in the upper parts of the uterus, and 
leaving the pelvic cavity quite unimplicated, may interfere with the 
action of the uterine fibres, prevent subsequent contraction, cause pro- 



376 LABOR. 

fuse post-partum hemorrhage, or even predispose to rupture of the 
uterine tissues. Hence, every case in which the existence of uterine 
fibroids has been ascertained must be anxiously watched. The risk of 
hemorrhage is perhaps the greatest ; for, if the tumors be at all large, 
efficient contraction of the uterus after the birth of the child must be 
more or less interfered with. Fortunately it is not so common as might 
almost be expected. Out of five cases recorded in the Obstetrical Trans- 
actions, two of which were in my own practice, no hemorrhage oc- 
curred ; nor does it seem to have happened in any of the twenty-six 
cases collected by Magdelaine in his thesis on the subject. I recently 
saw an interesting example of this in a patient whose case was looked 
forward to with much anxiety, in consequence of the existence of 
several enormous fibroid masses projecting from the fundus and 
anterior surface of the body of the uterus, and whose labor was, never- 
theless, typically normal in every way. Should hemorrhage occur 
after delivery, the injection of styptic solutions would probably be 
peculiarly valuable, since the ordinary means of promoting contraction 
are likely to fail. 

It is when the fibroid growths implicate the lower uterine zone and 
the cervical region that the greatest difficulties are likely to be met 
with. The practice then to be adopted must be regulated to a great 
extent by the nature of each individual case. If it be possible to push 
the tumor above the pelvic brim, out of the way of the presenting part, 
that, no doubt, is the best course to pursue, as not only clearing the 
passage in the most effectual way, but removing the tumor from the 
bruising to which it would otherwise be subjected when pressed between 
the head and the pelvic Avails, which seems to be one of the greatest 
dangers of this complication. This manoeuvre is sometimes possible 
in what seem to be the most unpromising circumstances. An interest- 
ing example is narrated by Sir Spencer Wells, 1 who, called to perform 
the Cesarean section, succeeded, although not without much difficulty, 
in pushing the obstructing mass above the brim, the child subsequently 
passing with ease. I have myself elsewhere recorded two similar 
cases 2 in which I was enabled to deliver the patient by pushing up the 
obstructing tumor, in both of which the Cesarean section would have 
been inevitable had the attempt at reposition failed. Therefore, before 
resorting to more serious operative procedures, a determined effort at 
pushing the tumor out of the way should be made, the patient being 
deeply chloroformed, and, if necessary, upward pressure being made 
by the closed fist passed into the vagina. 3 

Failing this, the possibility of enucleating the tumor, or if that be 
not possible, of removing it piecemeal with the ecraseur, should be 
considered. On account of the loose attachments of these growths, 
and the facility with which they can be removed in this way in the 
non -pregnant state, the expedient seems certainly well worthy a trial, 
if their site and attachments render it at all feasible. Interesting 
examples of the successful performance of this operation are recorded 

1 Obst. Trans., vol. ix. p. 73. 2 Ibid., vol xix. p. 101. 

3 This procedure is objected to in Dr. John Phillips's paper already quoted, but it seems to me 
on insufficient grounds. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 377 

by Danyau, Braxton Hicks, and Munde. Should it be found imprac- 
ticable, the case must be managed in reference to the amount of obstruc- 
tion ; and the forceps, craniotomy, or even one of the varieties of 
abdomiual section may be necessary. The results of even the improved 
Cesarean section have been very discouraging in such cases. Out. of 
forty-five of these operations collected by Harris, thirty-six proved 
fatal. Probably Porro's operation, or pan-hysterectomy, would give 
the patient a better chauce, and of the former, successful cases are 
recorded. 1 

The proportion of breech presentations in cases of fibro-myoma com- 
plicating delivery is much larger than usual ; out of one hundred cases 
Lefour 2 observed thirty-two breech presentations, and Chabazin gives 
the proportion as 26 per cent. This is probably due to the altered 
shape of the uterine cavity caused by the tumor. 

Tumors of the Ovaries. — The next most common class of obstruct- 
ing tumors are those of the ovary (Fig. 129), and it is apparently not 
the largest of these which are most apt to descend into the pelvic cavity. 
When the tumor is of any considerable size, its bulk is such that it 
cannot be contained in the true pelvis, and it rises into the abdominal 
cavity with the uterus. Hence, the existence of the tumor that offers 
the most formidable obstacle to delivery is rarely suspected before 
labor sets in ; in fact, the existence of a tumor is only discovered before 
labor in 18 per cent, of the cases referred to below. 

In order to estimate the results of the various methods of treatment, 
I have tabulated fifty-seven cases. 3 Dr. McKerron, 4 of Aberdeen, has 
recently written an exhaustive paper on this subject, in which he has 
collected one hundred and twenty-six more cases, making one hundred 
and eighty-three in all. In the following remarks I have added his 
results to those obtained from the cases I had previously collected. In 
thirty-five cases labor was terminated by the natural powers alone; 
but of these no less than twelve mothers died. In favorable contrast 
with these, we have the cases in which the size of the tumor was dimin- 
ished by puncture. These were forty-three in number, eight of the 
mothers, 18.6 per cent., dying, and twenty-four children. The 
reason of the great mortality in the former cases is apparently the 
bruising to which the tumor, even when small enough to allow the 
child to be squeezed past it, is necessarily subjected. This is extremely 
apt to set up a fatal form of diffuse inflammation, the risk of which 
was long ago pointed out by Ashwell, 5 who draws a comparison be- 
tween cases in which such tumors have been subjected to contusion and 
cases of strangulated hernia ; and the cause of death in both is doubtless 
very similar. This danger is avoided when the tumor is punctured, 
so as to become flattened between the head and the pelvic walls. On 
this account I think it should be laid down as a good general rule that 
puncture should be performed in all cases of ovariau tumor engaged in 
front of the presenting part, even when it is of so small a size as not to 
preclude the possibility of delivery by the natural powers. McKerron 

1 Harris's note sixth American edition. 

2 E. Blanc : Annal. de Gyn., torn xxxv. p. 1.97. 3 obst Trans., vol. ix. p. 69. 

4 Ibid., vol. xxxix. 1897. & Guy's Hospital Reports, No. 2, p. 300. 



378 



LABOR 



distrusts puncture, except in purely cystic tumors. It is to be noted, 
however, that accurate diagnosis as to the character of the tumor is 
not generally possible, and it seems to me that with careful antisepsis 
a preliminary puncture is the simplest and probably the safest proce- 
dure. In my cases reposition was only effected in five, or 10.5 per 
cent, of the cases ; in McKerron's additional cases it was practised 
thirty-five times, or 28 per cent., with a maternal mortality of only 8 
per cent, in the whole series. In a certain number of cases delivery 
was effected either alone, or in combination with reposition or punc- 
ture, by turning, forceps, or craniotomy. There are two successful 
cases of ovariotomy during the labor, and three in which the obstruct- 
ing ovary was removed per vaginam. In all of these the mothers re- 
covered. The Csesarean section was performed in eleven cases, with 
two recoveries. The worst results were in the cases allowed to remain 
long in labor, and even such formidable procedures as ovariotomy 




Labor complicated by ovarian tumor. 

during labor, or the Cesarean section, are preferable to this when the 
obstacle cannot be removed by reposition or puncture. I am inclined 
to think that vaginal extirpation, which appears to have been tried only 
in three cases, all of which recovered, would often be possible — since 
such obstructing tumors are always of small size — provided the case is 
in the hands of a practitioner accustomed to this method of operating, 
which has been much extended of late years in gynecological practice. 

After the labor is completed the subsequent management of the case 
will naturally be a matter for anxious consideration. On this Mc- 
Kerron comes to the following conclusions, which seem on the whole 
to be judicious : " 1. Where delivery has been effected by the Csesa- 
rean section the tumor should, if possible, be coincidently removed. 
2. Where the cyst-contents are proved or strongly suspected to be in- 
fective, or when the tumor has been subjected to long-continued pres- 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 379 

sure, abdominal ovariotomy should be done at once or within a few 
hours after delivery. 3. When the tumor has been subjected to con- 
siderable pressure before reposition and is believed to be a dermoid, 
removal should be effected at the end of the first week of the puer- 
perium. 4. "When reposition has been successful early in labor, or 
when puncture reveals the tumor to be a simple cyst, expectant treat- 
ment should be adopted, but the supervention of severe inflammatory 
symptoms should at once be followed by laparotomy. " 

The question of the effect on labor of ovarian tumor which does 
not obstruct the pelvic canal is one of some interest, but there are not 
a sufficient number of cases recorded to throw much light on it. I 
am disposed to think that labor generally goes on favorably. What 
delay there is depends on the inefficient action of the accessory 
muscles engaged in parturition, on account of the extreme distention 
of the abdomen. 

There are a few other conditions connected with the maternal struc- 
tures which may impede delivery, but which are of comparatively rare 
occurrence. 

Vaginal Cystocele. — Amongst them is vaginal cystocele, consisting 
of a prolapse of the distended bladder in front of the presentation, 
where it forms a tense fluctuating pouch which has been mistaken for 
a hydrocephalic head, or for the bag of membranes. This complica- 
tion is only likely to arise when the bladder has been allowed to become 
unduly distended from want of attention to the voiding of urine during 
labor. The diagnosis should not offer any difficulty, for the finger 
will be able to pass behind, but not in front of, the swelling, and 
reach the presenting part ; while the pain and tenesmus will further 
put the practitioner on his guard. The treatment consists in emptying 
the bladder ; but there may be some difficulty in passing the catheter, 
in consequence of the urethra being dragged out of its natural direction. 
A long elastic male catheter will almost always pass, if used with care 
and gentleness. Should it be found impossible to draw off the water 
— and this is said to have sometimes happened — the tense pouch might 
be punctured without danger by the fine needle of an aspirator trocar, 
and its contents withdrawn. When once the viscus is emptied, it can 
easily be pushed above the presenting part in the intervals between 
the pains. 

Vesical Calculus. — In some few cases difficulties have arisen from 
the existence of a vesical calculus. Should this be pushed down in 
front of the head, it can readily be understood that the maternal 
structures would run the risk of being seriously bruised and injured. 
Should we make out the existence of a calculus — and, if the presence 
of one be suspected, the diagnosis could easily be made by means of a 
sound — an endeavor should be made to push it above the brim of the 
pelvis. If that be found to be impossible, no resource is left but its 
removal, either by crushing, or by rapid dilatation of the urethra, 
followed by extraction. Should we be aware of the existence of a 
calculus during pregnancy, its removal should certainly be undertaken 
before labor sets in. 

Hernial protrusion in Douglas's space may sometimes give rise to 



380 LABOR. 

anxiety, from the pressure and contusion to which it is necessarily 
subjected. An endeavor must be made to replace it, and to moderate 
the straining efforts of the patient; and it may even be advisable to 
apply the forceps so as to relieve the mass from pressure as soon as 
possible. It is, however, of great rarity. Fordyce Barker, in an in- 
teresting paper on the subject, 1 records several examples, and states 
that he has met with no instance in which it has led to a fatal result, 
either to mother or child, although it cannot but be considered a serious 
complication. 

Scybalous masses in the intestines may be so hard and impacted 
as to form an obstruction. The necessity of attending to the state of 
the rectum has already been pointed out. Should it be found impos- 
sible to empty the bowel by large enemata, the mass must be mechan- 
ically broken down and removed by the scoop. 

CEdema of the Vulva. — Excessive oedematous infiltration of the 
vulva may sometimes cause obstruction, and require diminution in size, 
which can easily be effected by numerous small punctures. 

Hematoma into the cellular tissue of the vulva or vagina forms a 
grave complication of labor. Such blocd-swellings are most usually 
met with in one or both labia, or under the vaginal wall ; in the 
gravest forms, the blood may extend into the tissues for a considerable 
distance, as in the case recorded by Cazeaux, where it reached upward 
as far as the umbilicus in front, and as far as the attachment of the 
diaphragm behind. 

The conditions associated with pregnancy, the distention and en- 
gorgement to which the vessels are subjected, the interference with the 
return of the blood by the pressure of the head during labor, and the 
violent efforts of the patient, afford a ready explanation of the reason 
why a vessel may be predisposed to rupture and admit the extravasa- 
tion of blood. 

The accident is fortunately far from a common one, although a 
sufficient number of cases are recorded to make us familiar with its 
symptoms and risks. The dangers attending such effusions would 
seem to be great, if the statistics given by those who have written on 
the subject are to be trusted. Thus, out of one hundred and twenty- 
four cases collected by various French authors, forty-four proved fatal. 
Fordyce Barker points out that, since the nature and appropriate 
treatment of the accident have been more thoroughly understood, the 
mortality has been much lessened ; for out of fifteen cases reported by 
Scanzoni only one died, and out of twenty-two cases he had himself 
seen, two died, and all these three deaths were from puerperal fever, 
and not the direct result of the accident. 2 

The blood may be effused into any part of the pelvic cellular tissue, 
or into the labia. The accident most often happens during labor when 
the head is low down in the pelvis, not unfrequently just as it is about 
to escape from the vulva. Hence the extravasation is more often met 
with low down in the vagina, and more frequently in one of the labia 
than in any other situation. I have met with a case in which I had 

1 Amer. Joum. of Obst, vol. ix. p. 177. 2 The Puerperal Diseases, p. 60, 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 381 

every reason to believe that an extravasation of blood had occurred 
within the tissues immediately surrounding the cervix. It is natural 
to suppose that a varicose condition of the veins about the vulva 
would predispose to the accident, but in most of the recorded ex- 
amples this is not stated to have been the case. Still, if varicose 
veins exist to any marked degree, some anxiety on this point cannot 
but be felt. 

The thrombus occasionally, though rarely, forms before delivery. 
Most commonly it first forms toward the end of labor, or after the 
birth of the child. In the latter case it is probable that the laceration 
in the vessels occurred before the birth of the child, and that the 
pressure of the presenting part prevented the escape of any quantity 
of blood at the time of laceration. 

The symptoms are not by any means characteristic. Pain of a 
tearing character, occasionally very intense, and extending to the back 
and down the thighs, is very generally associated with the formation 
of the thrombus. If a careful physical examination be made, the 
nature of the case can readily be detected. When the blood escapes 
into the labium, a firm, hard swelling is felt which has even been mis- 
taken for the foetal head. If the eifusion implicate the internal parts 
only, the diagnosis may not at first be so evident. But even then a 
little care should prevent any mistake, for the swelling may be felt in 
the vagina, and may even form an obstacle to the passage of the 
child. Cazeaux mentions cases in which it was so extensive as to 
compress the rectum and urethra, and even to prevent the exit of the 
lochia. In some cases the distention of the tissues is so great that 
they lacerate, and then hemorrhage, sometimes so profuse as directly 
to imperil the life of the patient, may occur. The bursting of the 
skin may take place some time subsequent to the formation of the 
thrombus. Constitutional symptoms will be in proportion to the 
amount of blood lost, either by extravasation cr externally, after 
the rupture of the superficial tissues. Occasionally they are consider- 
able, and are the same as those of hemorrhage from any cause. 

The terminations of thrombus are either spontaneous absorption, 
which may occur if the amount of blood extra vasated be small ; or 
the tumor may burst, and then there is external hemorrhage ; or it 
may suppurate, the contained coagula being discharged from the cavity 
of the cyst ; or, finally, sloughing of the superficial tissues has occurred. 

The treatment must naturally vary with the size of the thrombus, 
and the time at which it forms. If it be met with during labor, 
unless it be extremely small, it will be very apt to form an obstruction 
to the passage of the child. Under such circumstances it is clearly 
advisable to terminate the labor as soon as possible, so as to remove 
the obstacle to the circulation in the vessels. For this purpose the 
forceps should be applied as soon as the head can be easily reached. 
If the tumor itself obstruct the passage of the head, or if it be of any 
considerable size, it will be necessary to incise it freely at its most 
prominent point and turn out the coagula, controlling the hemorrhage 
at once by filling the cavity with cotton wadding saturated in a solu- 
tion of perchloride of iron, while at the same time digital compression 



382 LABOR. 

with the tips of the fingers is kept up. By this means pressure is 
applied directly to the bleeding-point, and the hemorrhage can be 
controlled without difficulty. This is all the more necessary if spon- 
taneous rupture has taken place, for then the loss of blood is often 
profuse, and it is of the utmost importance to reach the site of the 
hemorrhage as nearly as possible. 

If the thrombus be not so large as to obstruct delivery, or if it be not 
detected until after the birth of the child, the question arises whether 
the case should not be left alone, in the hope that absorption may occur, 
as in most cases of pelvic hseinatocele. This expectant treatment is 
advised by Cazeaux, and it seems to be the most rational plan we can 
adopt. True, it may take a longer time for the patient to convalesce 
completely than if the coagula were removed at once, and the hemor- 
rhage restrained by pressure on the bleeding-point; but this disad- 
vantage is more than counterbalanced by the absence of risk from 
hemorrhage, and of septicemia from the suppuration that must 
necessarily follow. Softening and suppuration may in many cases 
occur in a few days, necessitating operation, but the vessels Avill then 
be probably occluded, and the risk of hemorrhage be much lessened. 
The late Dr. Fordyce Barker, however, held the opposite opinion, 
and thought that the proper plan was to open the thrombus early, 
controlling the hemorrhage in the manner already indicated, unless 
the thrombus is situated high in the vaginal canal. 

Whenever the cavity of a thrombus has been opened, either by in- 
cision or by spontaneous softening at some time subsequent to its 
formation, it must not be forgotten that there is considerable risk of 
septic absorption. To avoid this, care must be taken to use antiseptic 
dressings freely, such as iodoform powder or wool, applied directly to 
the part, and frequent vagiual injections of diluted Condy's fluid. 
Barker laid special stress upon the importance of not removing 
prematurely the coagula formed by the styptic aj^plications, for fear 
of secondary hemorrhage, but of allowing them to come away 
spontaneously. 



DYSTOCIA FROM FCETUS. 



383 



CHAPTER XI. 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL 
CONDITION OF THE FCETUS. 

Plural Births. — The subject of multiple pregnancy in general 
having already been fully considered, we have now only to discuss its 
practical beariug as regards labor. Fortunately, the existence of 
twins rarely gives rise to any serious difficulty. In the large propor- 
tion cf cases the presence of a second foetus is not suspected until the 
birth of the first, when the nature of the case is at once apparent from 
the fact of the uterus remaining as large, or nearly as large, as it was 
before. 

There may possibly be some delay in the birth of the first child, 
inasmuch as the extreme distention of the uterus may interfere with 



Fig. 130. 




Twin pregnancy, breech and head presenting. 



its thoroughly efficient action ; while, in addition, the uterine pressure 
is not directly conveyed to the ovum as in single births, but in- 
directly through the amniotic sac of the second child (Fig. 130). Such 
delay is especially apt to ari^e when the first child presents by the 
breech, for, even if the body be expelled spontaneously, difficulty is 
likely to occur with the head, since the uterus does not contract upon 



384 LABOR. 

it as is ordinarily the case. Hence the intervention of the accoucheur 
to save the life of the child, by the extraction of the head, will be 
almost a matter of necessity. 

In the majority of cases, after the birth of the first child, there is a 
temporary lull in the pains, which soon recommence, generally in 
from ten to twenty minutes, and the second child is rapidly expelled ; 
for on account of the full dilatation of the soft parts, there is no 
obstacle to its delivery. Sometimes there is a considerable interval 
before the pains recur, and instances are recorded in which even, 
several days elapsed between the births of the two children. 

Treatment. — In most cases the management of twins does not differ 
from that of ordinary labor. As soon as we are certain of the exist- 
ence of a second foetus^ we should inform the bystanders, but not 
necessarily the mother, to whom the news might prove an unpleasant 
and even dangerous shock. Then, having taken care to tie the cord 
of the first child for fear of vascular communication between the pla- 
centae, our duty is to wait for a recurrence of the pains. If these come 
on rapidly, and the presentation of the second foetus be normal, its 
birth is managed in the usual way. 

If there be any unusual delay, we have to consider the proper course 
to pursue, and on this the opinions of authorities differ greatly. Some 
advise a delay of several hours, and even more, if pains do not recur 
spontaneously ; while others — Murphy, for example — recommend that 
the second child should be delivered at once. Either extreme of prac- 
tice is probably wrong, and the safest and best course is, doubtless, the 
median one. The second point to bear in mind is, that in multiple 
pregnancy, on account of the extreme distention of the uterus, there is 
a tendency to inertia, and consequently to post-partum hemorrhage ; 
and that, therefore, it is better that the birth of the second child should 
be delayed, even for a considerable time, rather than that the patient 
should run the risk attending an empty and uncontracted uterus. If, 
however, uterine action be present, there is an obvious advantage in 
the delivery of the second child before the dilatation of the passages 
passes off. 

The best plan would seem to be, if, after waiting a quarter of an 
hour, labor-pains do not occur, to try and induce them by uterine fric- 
tion and pressure, and by the administration of a dose of ergot, to 
which, as there can be no obstacle to the rapid birth of the second 
child, there can be now no objection. The membranes of the second 
child should always be ruptured at once, if easily within reach, as one 
of the speediest means of inducing contraction. If no progress be 
made, and speedy delivery be indicated — a necessity which may arise 
either from the exhausted state of the patient, the presence of hemor- 
rhage, extremely feeble pulsations of the foetal heart (showing that the 
life of the second child is endangered), or malpresentation of the 
second foetus — turning is probably the readiest and safest expedient. 
Under such circumstances the operation is performed with great ease, 
since the passages are amply dilated. After bringing down the feet, 
the birth of the body should be slowly effected, with the view of insur- 
ing as complete subsequent contraction as possible. If the head has 



DYSTOCIA FROM FGETUS 



385 



descended in the pelvis, of course turning is impossible, and the forceps 
must be applied. 

Difficulties arising* from Locked Twins. — Occasionally very 
serious difficulties arise from parts of both foetuses presenting simulta- 
neously, and thus impeding the entrance of either child into the pelvis, 
or getting locked together, so as to render delivery impossible without 
artificial aid. Such difficulties are not apt to arise in the more ordi- 
nary cases, in which each child has its own bag of membranes, since 
then the foetuses are kept entirely separate ; but in those in which the 
twins are contained in a common amniotic cavity, or in which both 
sacs have burst simultaneously. They are very puzzling to the obste- 
trician, and it may be far from easy to discover the cause of the 
obstruction ; however, by careful examination — passing, if necessary, 
the whole hand into the vagina, under an anaesthetic, combined with 
abdominal palpation — the true position of the foetuses may generally be 
made out. Nor is it possible to lay down any positive rules for their 
management, which must be governed, to a considerable extent, by the 
circumstances of each individual case. 

Fig. 131. 




Shows head-locking, both children presenting head first. (After Barnes.) 

Sometimes both heads present simultaneously at the brim, and then 
neither can enter unless they be unusually small or the pelvis very 
capacious, when both may descend; or rather the first head may 
descend low into the pelvic cavity, and then the second head enters the 
brim, and gets jammed against the thorax of the first child (Fig. 131). 

Reimann relates a curious example of this, in which he delivered 
the head first with the forceps, but found the body would not follow, 
and, on examination, a second head was found in the pelvis. He then 
applied the forceps to the second head ; the body of the first child was 
then born, and afterward that of the second. Such a mechanism must 

25 



386 LABOR. 

clearly have been impossible unless the pelvis had been extremely 
large. 

Whenever both heads are felt at the brim, it will generally be found 
possible to get one out of the way by appropriate manipulation, one 
hand being passed into the vagina, the other aiding its action from 
without. Then the forceps may be applied to the other head, so as to 
engage it at once in the pelvic cavity. If both have actually passed 
into the pelvis, as in the case just alluded to, the difficulty will be 
much greater. It will generally be easier to push up the second head 
while the lower is drawn out by the forceps, than to deliver the second, 
leaving the first in situ. 

In other cases a foot or a hand may descend along with the head, 
and even the four feet may present simultaneously. The rule in the 
former case is to push the part descending with the head out of the 
way, and in the latter to disengage one child as soon as possible. 
Great care is necessary, or we might possibly bring down the limbs of 
separate children. 

The most common kind of difficulty is when the first child presents 
by the breech, and is delivered as far as the head, which is then found 
to be locked with the head of the second child, which has descended 
into the pelvic cavity (Fig. 132). 

Here it is clear that the obstruction must be very great, and, unless 
the children are extremely small, insuperable. The first endeavor 
should be to disentangle the heads ; this is sometimes feasible if the 
second be not deeply engaged in the pelvis, and the hand be passed up 
so as to push it out of the way. This will but rarely succeed ; then it 
may be possible to apply the forceps to the second head and drag it 
past the body of the first child, and this is the method recommended 
by Reimann, who has written an excellent paper on the subject. 1 
Generally the sacrifice of one of the children is essential, and as the 
body of the first child must have been born for some time, it is prob- 
able that the pressure to which it has been subjected will have already 
imperilled, if it has not destroyed, its life, and therefore the plan 
usually recommended is to decapitate. This can be easily done with 
scissors or a wire 6craseur, after which the second child is expelled 
without difficulty, leaving the head of the first in utero to be subse- 
quently dealt with. 

Another mode of managing these cases is to perforate the upper head 
and draw it past the lower with the cephalotribe or craniotomy forceps. 
This plan has the disadvantage of probably sacrificing both children, 
since the other child can hardly survive the pressure and delay, whereas 
the former plan gives the second child a fair chance of being born alive. 

Double Monsters. — In connection with the subject of twin labor 
we may consider those rare cases in which the bodies of the foetuses are 
partially fused together. The mechanism and management of delivery 
in cases of double monstrosity have attracted comparatively little atten- 
tion, no doubt because authors have considered them matters of curi- 
osity merely, rather than of practical importance. 

1 American Journal of Obstetrics, vol. x. p. 47. 



DYSTOCIA FROM FCETUS 



387 



The frequent occurrence of such monstrosities in our museums, and 
the numerous cases scattered through our periodical literature, are 
sufficient to show that they are not so very rare as we might be inclined 
to imagine ; and, as they are likely to give rise to formidable difficulties 
in delivery, it cannot be unimportant to have a clear idea of the usual 
course taken by nature in effecting such births, with a view of enabling 
us to assist in the most satisfactory manner should a similar case come 
under our observation. 



Ftg. 132. 




Shows head-locking, first child coming feet first ; impaction of heads from wedging in brim. d. 
Apex of wedge. E. c. Ease of wedge, which cannot enter brim. a. b. Line of decapitation to 
decompose wedge, and enable head of second child to pass. (After Barnes.) 

Unfortunately, the authors who have placed on record the birth of 
double monsters have generally occupied themselves more with a 
description of the structural peculiarities of the foetuses than with the 
mechanism of their delivery; so that, although the cases to be met with 
in medical literature are very numerous, comparatively few of them 
are of real value from an obstetric point of view. Still, I have been 



388 LABOR. 

able to collect the details of a considerable number 1 in which the his- 
tory of the labor is more or less accurately described ; and doubtless a 
more extensive research would increase the list. 

Double Monstrosity may be Divided into Pour Classes. — For 
obstetric purposes we may confine our attention to four principal 
varieties of double monstrosity, which are met with far more frequently 
than any others. These are : 

A. Two nearly separate bodies united in front to a varying extent, 
by thorax or abdomen. 

B. Two nearly separate bodies united back to back by the sacrum 
and lower part of the spinal column. 

C. Dicephalous monsters, the bodies being single below, but the 
heads separate. 

D. The bodies separate below, but the heads partially united. 
This classification by no means includes all the varieties of monsters 

that we may meet with. It does, however, include all that are likely 
to give rise to much difficulty in delivery ; and all the cases I have 
collected may be placed under one of these divisions. 

The first point that strikes us in looking over the history of these 
deliveries is the frequency with which they have been terminated by 
the natural powers alone, without any assistance on the part of the 
accoucheur. Thus, out of the 31 cases, no less than 20 were delivered 
naturally, and apparently without much trouble. Nothing can better 
show the wonderful resources of Nature in overcoming difficulties of a 
very formidable kind. 

It is pretty generally assumed by authors that the children are 
necessarily premature, and therefore of small size, and that delivery 
bofore the full term is rather the rule than the exception. Duges 
states that the children are often dead, and that putrefaction has taken 
place, which facilitates their expulsion. Both these assumptions seem 
to me to have been made without sufficient authority, and not to be 
borne out by the recorded facts. In only one of the 31 cases is it men- 
tioned that the children were premature ; nor is there any sufficient 
reason that I can see why labor should commence before the full term 
of gestation. 

Class A. — By far the greatest number are included in the first 
class — that in which the bodies are nearly separate, but united by some 
part of the thorax or abdomen. This is the division which includes 
the celebrated Siamese Twins, an account of whose birth, I may ob- 
serve, I have Dot been able to discover. 2 Out of the 31 cases, 19 come 
under this heading. The details of the labors are briefly as follows: 
1 died undelivered ; 8 were terminated by the natural powers (in three 
of which the feet, and in three the head presented, in two the presen- 
tation is doubtful) ; 6 were delivered by turning, or by traction on the 
lower extremities ; 4 were delivered instrumentally. 

1 Obst. Trans, vol. viii. p. 300. 

2 The mother of these twins was a Chinese half-breed, short, and with a broad pelvis, and had 
borne several children previously. She stated on several occasions, in conversation with parties 
in Siam, that the twins were born reversed, the feet of one being followed by the head of the 
other, and that they were very small and feeble at birth and for several months afterward. The 
twins confirmed this statement by affirming that thev could, when little boys at play on the 
ground, turn themselves end for end upon the ensiform attachment up to the age of ten or twelve, 
the attachment being then soft and pliable.— Harris's note to second American edition. 



DYSTOCIA FROM FCBTUS. 389 

The details of the cases in which the feet presented, or in which 
turning was performed, clearly show that footling presentation was 
by far the most favorable, and it is fortunate that the feet often present 
naturally. The inference, of course, is that version should be resorted 
to whenever any other presentation is met with in cases of double 
monstrosity of this type ; but, unfortunately, this rule could rarely be 
carried into execution, since we possess no means of diagnosing the 
junction of the foetuses at a sufficiently early stage of labor to admit 
of turning being performed. It is only under exceptionally favorable 
circumstances that this can be done ; as, for example, in a case recorded 
by Molas, in which both heads presented, but neither would enter the 
brim of the pelvis. 

The great difficulty must, of course, be in the delivery of the heads, 
for in all the recorded cases, with one exception, the bodies have passed 
through the pelvis parallel to each other with comparative ease until 
the necks have appeared, and then, as a rule, they could be brought 
no further. It is clear that the remainder of the foetuses could no 
longer pass simultaneously ; and, were direct traction continued, the 
heads would be inextricably fixed above the brim. In accordance 
with the direction of the pelvic axes the posterior head must first 
engage in the inlet ; and, in order to effect this, it will be necessary to 
carry the bodies of the children well over the abdomen of the mother. 
This seems to be a point of primary importance. It would also be 
advisable to see that the bodies are made to pass through the pelvis 
with their backs in the oblique diameter. By this means more space 
is gained than if the backs were placed antero-posteriorly ; while, at 
the same time, there is less chance of the heads hitching against the 
promontory of the sacrum and symphysis pubis, which otherwise would 
be very apt to occur. 

When the head presents, and the labor is terminated by the natural 
powers, delivery seems to be accomplished in one of two ways. 

In the first and more common, the head and shoulders of one child 
are born, its breech and legs being subsequently pushed through the 
pelvis by a process similar to that of spontaneous evolution ; and, 
afterward, the second child probably passes footling without much 
difficulty. 

Barkow relates a case in which both heads were delivered by the 
forceps, the bodies subsequently passing simultaneously. Two similar 
instances are recorded in the third and sixth volumes of the Obstetrical 
Transactions. When delivery takes places in this manner, the head 
of the second child must fit into the cavity formed by the neck of the 
first, and the pelvis must necessarily be sufficiently roomy to admit of 
the expulsion of the head of the second child while its cavity is dimin- 
ished in size by the presence of the. neck and shoulders of the first. 
Either of these processes must obviously require exceptionally favor- 
able conditions as regards the size of the child and the pelvis ; and the 
difficulty in the way of delivery must be much greater than when the 
lower extremities present. Therefore, I think the rule should be laid 
down that, when the nature of the case is made out (and for the pur- 
pose of accurate diagnosis a complete examination under anaesthesia 



390 LABOR. 

should be practised), turning should be performed, and the feet brought 
down. 

In the event of its being found impossible to effect delivery after a 
considerable portion of the bodies is born, no resource remains but the 
mutilation of the body of one child, so as to admit of the passage of 
the other. This was found necessary in one case in which the children 
presented by the feet, and were born as far as the thorax, but could 
get no further. The body of the anterior child was removed by a 
circular incision as far as it had been expelled, which allowed the 
remaining portion, consisting of the head and shoulders, to re-enter 
the uterus ; after this the posterior child was easily extracted, and the 
mutilated foetus followed without difficulty. 

Class B. — In class B, in which the children are united back to back, 
three cases are recorded, all of which were delivered by the natural 
powers. One of these is the case of Judith and Helene, the celebrated 
Hungarian twins, who lived to the age of twenty. Helene was born 
as far as the umbilicus, and, after the lapse of three hours, her breech 
and legs descended. Judith was expelled immediately afterward, her 
feet descending first. 1 Exactly the same process occurred in a case 
described by M. Norman, the children being also born alive, and dying 
on the ninth day. 

It is probable that labor is easier in this class of double monsters 
than in the former, because the children are so joined that there 
is no necessity for the bodies to be parallel to each other during 
birth when the head presents, and after the birth of the head and 
shoulders of the first child, its breech and lower extremities are 
evidently pushed down and expelled by a process of spontaneous evo- 
lution. If the feet originally presented, the mechanism of delivery 
and the rules to be followed would be the same as in class A ; but the 
difficulty would probably be greater, since the juncture is not so flexible, 
and a more complete parallelism of the bodies Mould be necessary 
during extraction. 

Class C. — In class C, that of the dicephalous monster, I have found 
the description of the birth of eight cases, three of which were termi- 
nated by the natural powers. In two of these, the process of evolution 
was the main agent in delivery ; one head being born and becoming 
fixed under the arch of the pubes, the body being subsequently pushed 
past it, and the second head following without difficulty. This process 
failing, the proper course is to decapitate the first-born head, and then 
bring down the feet of the child, when delivery can be accomplished 
with ease. This was the course adopted in two out of the eight cases; 
and it may be done with the less hesitation since, from their structural 
peculiarities, it is extremely improbable that monsters of this kind 
should survive. In the third case, terminated naturally, the heads 
were said to have been born simultaneously, but it seems probable that 
the one head lay in the hollow formed by the neck of the other, and so 

1 The celebrated Carolina twins, born July 11, 1851, and still living, were brought into the world 
bv the same method, but the mother, having a large pelvis, had " a brief and easy " delivery. The 
larger of the two girls also came first, as in the Tzoni case of 1751. These twins are seven years 
older than the Hungarian sisters were at death.— Harris's note to third American edition. 



DYSTOCIA FROM FCETUS. 391 

rapidly followed it. If the feet presented, the case might be managed 
in the same manner as in class A. 

Class D. — Monstrosities of class D, in which the heads are united, 
the bodies being distinct, appear to be the most uncommon of all ; and 
I can find the description of delivery in only two cases. One of these 
gave rise to great difficulty ; the labor iu the other was easy. We 
should scarcely anticipate much difficulty in the birth of monsters of 
this type ; for, if the head presented and would not pass, we should 
naturally perform craniotomy ; and if the bodies came first, the delivery 
of the monstrous head could readily be accomplished by perforation. 

The result to the mothers in all these cases seems to have been 
very favorable. There is only one in which the death of the mother 
is recorded ; and although in many the result is not mentioned, we 
may fairly assume that recovery took place. 

Among difficulties in labor, some of the most important are due to 
morbid conditions of the foetus itself. 

Intra-uterine Hydrocephalus. — Of these, the most common, as 
well as the most serious, is caused by intra-uterine hydrocephalus 
(giving rise to a collection of watery fluid within the cranium), by 
which the dimensions of the child's head are enormously increased, 
and the due relations between it and the pelvic cavity entirely de- 
stroyed (Fig. 133). 

Fortunately this disease is of comparatively rare occurrence, for it is 
one of great gravity both as regards the mother and child. As regards 
the mother, the serious character of the complication is proved by the 
statistics of Dr. Thomas Keith, then of Edinburgh, who found that out 
of seventy-four cases no less than sixteen were accompanied by rupture 
of the uterns. The reason of the danger to which the mother is 
subjected is obvious. In some few cases, indeed, the head is so com- 
pressible that, provided the amount of contained fluid be small, it may 
be sufficiently diminished in size, by the moulding to which it is sub- 
jected, to admit of its being squeezed through the pelvis. In the 
majority of cases, however, the size of the head is too great for this 
to occur. The uterus therefore exhausts itself, and may even rupture, 
in the vain endeavor to overcome the obstacle; while the large and 
disteuded head presses firmly on the cervix, or on the pelvic tissues, 
if the os be dilated, and all the evil effects of prolonged compression 
are apt to follow. 

Diagnosis. — The diagnosis of intra-uterine hydrocephalus is by no 
means so easy as the description in obstetric works would lead us to 
believe. It is true that the head is much larger and more rounded in 
its contour than the healthy foetal cranium, and also that the sutures 
and fontanelles are more wide, and admit occasionally of fluctuation 
being perceived through them. Still it is to be remembered that the 
head is always arrested above the brim, where it is consequently high 
up and difficult to reach, and where these peculiarities are made out 
with much difficulty. As a matter of fact, the true nature of the case is 
comparatively rarely discovered before delivery; thus Chaussier 1 found 

i Gazette Mt-dicale. 1864, 



392 



LABOR. 



that in more than one-half of the cases he collected, an erroneous 
diagnosis had been made. 

Whenever we meet with a case in which either the history of pre- 
vious labor, or a careful examination, convinces us that there is no 
obstacle due to pelvic deformity, in which the pains are strong and 
forcing, but in which the head persistently refuses to engage in the 
brim, we may fairly surmise the existence of hydrocephalus. Nothing, 
however, short of a careful examination under anaesthesia, the whole 
hand being passed into the vagina so as to explore the presenting part 
thoroughly, will enable us to be quite sure of the existence of this com- 
plication. Under these circumstances such a complete examination is 
not only justified but imperative ; and, when it has been made, the 
difficulties of diagnosis are lessened, for then we may readily make out 

Fig. 133. 




Labor impeded by hydrocephalus. 

the large round mass, softer and more compressible than the healthy 
head, the widely separated sutures, and the fluctuating fontanelles. 

In a considerable proportion of cases — as many, it is said, as one 
out of five — the foetus presents by the breech. The diagnosis is then 
still more difficult ; for the labor progresses easily until the shoulders 
are born, when the head is completely arrested, and refuses to pass 
with any amount of traction that is brought to bear on it. Even the 
most careful examination may not enable us to make out the cause of 
the delay, for the finger will impinge on the comparatively firm base 
of the skull, and may be unable to reach the distended portion of the 
cranium. At this time abdominal palpation might throw some light 
on the case; for, the uterus being tightly contracted round the head, 
we might be able to make out its unusual dimensions. The wasted and 
shrivelled appearance of the child's body, w T hich so often accompanies 
hydrocephalus, would also arouse suspicion as to the cause of delay. 
On the whole, such cases may be fairly assumed to be less dangerous to 



DYSTOCIA FROM FCETUS. 393 

the mother than when the head presents ; for, in the latter, the soft 
parts are apt to be subjected to prolonged pressure and contusion ; 
while, in the former, delay does not commence till after the shoulders 
are born, and then the character of the obstacle would be sooner dis- 
covered, and appropriate means earlier taken to overcome it. 

Treatment. — The treatment is simple, and consists in tapping the 
head, so as to allow the cranial bones to collapse. There is the less 
objection to this course, since the disease almost necessarily precludes 
the hope of the child's surviving. The aspirator would draw off the 
fluid effectually, and would at least give the child a chance of life ; 
and, under certain circumstances, the birth of a child who lives for a 
short time only may be of extreme legal importance. More generally 
the perforator will be used, and as soon as it has penetrated, a gush of 
fluid will at once verify the diagnosis. Schroeder recommends that, 
after perforation, turning should be performed, on account of the diffi- 
culty with which the flaccid head is propelled through the pelvis. 
This seems a very unnecessary complication of an already sufficiently 
troublesome case. As a rule, when once the fluid has been evacuated, 
the pains being strong, as they generally are, no delay need be appre- 
hended. Should the head not come down, the cephalotribe may be 
applied, which takes a firmer grasp than the forceps, and enables the 
head to be crushed to a very small size and readily extracted. 

When the breech presents, the head must be perforated through the 
occipital bone, and generally this may be accomplished behind the ear 
without much difficulty. In a case of Tarnier's the vertebral column 
was divided by a bistoury and an elastic male catheter introduced into 
the vertebral canal, through which the mtra-cranial fluid escaped, the 
labor being terminated spontaneously. 1 In any case in which it is 
found difficult to reach the skull with the perforator this procedure 
should certainly be tried. 

Other forms of dropsical effusion may give rise to some diffi- 
culty, but by no means so serious. In a few rare cases the thorax has 
been so distended with fluid as to obstruct the passage of the child. 
Ascites is somewhat more common, and occasionally the child's bladder 
is so distended with urine as to prevent the birth of the body. The 
existence of any of these conditions is easily ascertained ; for the head 
or breech, whichever happens to present, is delivered without difficulty, 
and then the rest of the body is arrested. This will naturally cause 
the practitioner to make a careful exploration, when the cause of the 
delay will be detected. 

The treatment consists in the evacuation of the fluid by puncture. 
In the case of ascites, this should always be done, if possible, by a 
fine trocar or aspirator, so as not to injure the child. This is all the 
more important since it is impossible to distinguish a distended bladder 
from ascites, and an opening of any size into that viscus might prove 
fatal, whereas aspiration would do little or no harm, and would prove 
quite as efficacious. 

Foetal Tumors Obstructing- Delivery. — Certain foetal tumors may 

1 Hergott : Maladies Fcetales qui peuvent faire obstacle h. l'accouchement. Paris, 1878. 



394 LABOR. 

occasion dystocia, such as malignant growths, or tumors of the kidney, 
liver, or spleen. Cases of this kind are recorded in most obstetric 
works. Hydro encephalocele, or hydro-rhachitis, depending on defective 
formation of the cranial or spinal bones, with the formation of a large 
protruding bag of fluid, is not very rare. The diagnosis of all such 
cases is somewhat obscure, nor is it possible to lay down any definite 
rules for their management, which must vary according to the par- 
ticular exigencies. The tumors are rarely of sufficient size to prove 
formidable obstacles to delivery, and many of them are very com- 
pressible. This is specially the case with the spina bifida and similar 
cystic growths. Puncture — and, in the more solid growths of the 
abdomen or thorax, evisceration — may be required. 

Other deformities, such as the auencephalous foetus, or defective 
development of the thorax or abdominal parietes with protrusion of 
the viscera, are not likely to cause difficulty ; but they may much 
embarrass the diagnosis by the strange and unusual presentation that 
is felt. If, in any case of doubt, a full and careful examination be 
undertaken, introducing the whole hand if necessary, no serious mis- 
take is likely to be made. 

Dystocia from Excessive Development of the Foetus. — In 
addition to dystocia from morbid conditions of the foetus, difficulties 
may arise from its undue development, and especially from excessive 
size and advanced ossification of the skull. This last is especially 
likely to cause delay. Even the slight difference in size between the 
male and female head was found by Simpson to have an appreciable 
effect in increasing the difficulty of labor, when the statistics of a 
large number of cases were taken into account ; for he proved, beyond 
doubt, that the difficulties and casualties of labor occurred in decidedly 
larger proportion in male than in female births. Other circumstances, 
besides sex have an important effect on the size of the child. Thus 
Duncan and Hecker have shown that it increases in proportion to the 
age of the mother and the frequency of the labors ; while the size of 
the parents has no doubt also an important bearing on the subject. 

Although these influences modify the results of labor en masse, they 
have little or no practical bearing on any particular case, since it is 
impossible to estimate either the size of the head or the degree of its 
ossification until labor is advanced. 

Treatment. — When labor is retarded by undue ossification or large 
size of the head, the case must be treated on the same general principles 
which guide us when the want of proportion is caused by pelvic con- 
traction. Hence, if delay arise which the natural powers are insuffi- 
cient to overcome, it will seldom happen that the disproportion is too 
great for the forceps to overcome. If we fail to deliver by it, no 
resource is left but perforation. 

Large size of the body of the child is etill more rarely a cause of 
difficulty ; for, if the head be born, the compressible trunk will almost 
always follow. Still, a few authentic cases are on record in which it 
was found impossible to extract the foetus on account of the unusual 
bulk of its shoulders and thorax. Should the body remain firmly 
impacted after the birth of the head, it is easy to assist its delivery by 



DYSTOCIA FROM FCETUS. 395 

traction on the axilla?, by gently aiding the rotation of the shoulders 
into the antero-posterior diameter of the pelvic cavity, and, if neces- 
sary, by extracting the arms, so as to lessen the bulk of the part of 
the body contained in the pelvis. Hicks relates a case in which 
evisceration was required for no other apparent reason than the 
enormous size of the body. The necessity for any such extreme 
measure must, of course, be of the greatest possible rarity ; and it is 
quite exceptional for difficulty from this source to be beyond the 
powers of Nature to overcome. 

Dystocia from Shortness of the Umbilical Cord. — Occasional 
difficulty in labor arises from uudue shortness of the umbilical cord. 
Although this is not, strictly speaking, due to auy cause connected 
with the foetus itself, it may best be considered here. Shortness of the 
umbilical cord may be actual, although this is comparatively rare, or 
relative — that is to say, when a cord of normal length is twisted round 
the neck or limbs of the foetus so as to obstruct delivery of the pre- 
senting part. Cases of the latter kind are common enough when, the 
head being born, the cord is found to be twisted two or three times 
rouud the neck, and the further progress of the head is arrested. This 
cause of dystocia has been well studied by Matthews Duncan, 1 and he 
refers to cases in which the tension of the short or shortened cord has 
either led to its rupture, to premature separation of the placenta, or 
even to partial or complete inversion of the uterus. In this contin- 
gency accurate diagnosis of the cause of delay would be difficult or im- 
possible, aud probably it could only be ascertained after delivery by 
forceps or otherwise. In the more common cases, after the birth of 
the head the twisting of the cord round the neck is, of course, at once 
observed, and then the obvious thing to do is to draw down some of 
it so as to slacken it, and then to pull the loop over the head. Gen- 
erally this can be done without much difficulty. If it cannot be easily 
accomplished, then the cord must be tied in situ, or divided with 
scissors if it is too tightly twisted to tie, the foetal portion being liga- 
tured after the birth of the body. In cases left to themselves, Duncan 
describes delivery as being completed by a process somewhat analogous 
to spontaneous evolution, the neck being fixed under the pubes. 

1 ' On Shortness of the Cord as a Cause of Obstruction to the Natural Progress of Labor." Obst. 
Trans., vol. xxxiii. 



396 LABOR. 



CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Deformities of the Pelvis form one of the most important subjects 
of obstetric study, for from them arise some of the gravest difficulties 
and dangers connected with parturition. A knowledge, therefore, of 
their causes and effects, and of the best mode of detecting them, either 
during or before labor, is of paramount necessity ; but the subject is 
far from easy, and it has been rendered more difficult than need be, 
from over-anxiety on the part of obstetricians to force all varieties of 
pelvic deformities within the limits of their favorite classification. 

Difficulties of Classification. — Many attempts in this direction 
have been made, some of which are based on the causes on which the 
deformities depend, others on the particular kind of deformity pro- 
duced. The changes of form, however, are so various and irregular, 
and similar, or apparently similar, causes so constantly produce dif- 
ferent effects, that all such endeavors have been more or less unsuc- 
cessful. For example, we find that rickets (of all causes of pelvic 
deformity the most important) generally produces a narrowing of the 
conjugate diameter of the brim ; Avhile the analogous disease, osteo- 
malacia, occurring in adult life, generally produces contraction of the 
transverse diameter, with approximation of the pubic bones, and rela- 
tive or actual elongation of the conjugate diameter. We might, 
therefore, be tempted to classify the results of these two diseases under 
separate heads, did we not find that, when rickets affects children who 
are running about, and subject to mechanical influences similar to 
those acting upon patients suffering from osteomalacia, a form of 
pelvis is produced hardly distinguishable from that met with in the 
latter disease, which by some authors is described as the pseudo- 
osteomalacic. 

On the whole, therefore, the most simple, as well as the most 
scientific, classification is that which takes as its basis the £>articular 
seat and nature of the deformity. Let us first glance at the most 
common causes. 

Causes of Pelvic Deformity. — The key to the particular shape 
assumed by a deformed pelvis will be found in a knowledge of the 
circumstances which lead to its regular development and normal shape 
in a state of health. The changes produced may, almost invariably, 
be traced to the action of the same causes which produce a normal 
pelvis, but which, under certain diseased conditions of the bones or 
articulations, induce a more or less serious alteration in form. These 
have been already described in discussing the normal anatomy of the 
pelvis, and it will be remembered that they are chiefly the weight of 



DEFORMITIES OF THE PELVIS. 397 

the body, transmitted to the iliac bones through the sacro-iliac joints; 
counter-pressure on these, acting through the acetabula ; and the action 
of the muscles and ligaments attached to the pelvic bones. Sometimes 
thev act in excess on bones which are healthy, but possibly smaller 
than usual, and the result may be the formation of certain abnormali- 
ties in the size of the various pelvic diameters. At other times they 
operate on bones which are softened and altered in texture by disease, 
aud which therefore yield to pressure far more than healthy bones. 

Rickets and Osteomalacia. — The two diseases which chiefly oper- 
ate in causing deformity are rickets and osteomalacia. Into the 
essential nature and symptomatology of these complaints it would be 
out of place to enter here ; it may snffice to remind the reader that 
they are believed to be pathologically similar diseases, with the im- 
portant practical distinction that the former occurs in early life, before 
the bones are completely ossified, and that the latter is a disease of 
adults, producing a softening in bones that have been hardened and 
developed. This difference affords a ready explanation of the gener- 
ally resulting varieties of pelvic deformity. 

Rickets commences very early in life, sometimes, it is believed, even 
in utero. It rarely produces softening of the entire bones, and only 
in case of very great severity, of those parts of the bones that have 
been already ossified. The effects of the disease are principally 
apparent in the cartilaginous portions of the bones, in which osseous 
deposit has not yet taken place. The bones, therefore, are not subject 
to uniform change, and this fact has an important influence in 
determining their shape. Rickety children also have imperfect mus- 
cular development ; they do not run about in the same way as other 
children, they are often continuously in the recumbent or sitting pos- 
ture, and thus the weight of the trunk is brought to bear, more than 
in a state of health, on the softened bones. For the same reason 
counter-pressure through the acetabula is absent, or comparatively 
slight. When, however, the disease occurs for the first time in chil- 
dren who are able to run about, the latter comes into operation, and 
modifies the amount and nature of the deformity. It is to be observed 
that in rickety children the bones are not only altered in form from 
pressure, but are also imperfectly developed, and this materiallv 
modifies the deformity. AVhen ossific matter is deposited, the bones 
become hard and cease to bend under external influences, and retain 
for ever the altered shape they have assumed. 

Osteomalacia. — In osteomalacia, on the contrary, the already 
hardened bones become softened uniformly through all their tex- 
tures, and thus the changes which are impressed upon them are 
much more regular and more easily predicated. It is, however, an 
infinitely less common cause of pelvic deformity than rickets, as is 
evidenced by the fact that in the Paris Maternity, in a period of 
sixteen years, 4<>2 eases of deformity due to rickets occurred to one 
due to osteomalacia. 1 

Their Varying" Frequency. — The frequency of both diseases varies 

1 Stanesco : Recherches cliniquos sur les Retrecissements du Bassin. 



398 LABOR. 

greatly in different countries and under different circumstances. 
Rickets is much more common amongst the poor of large cities, whose 
children are ill-fed, badly-clothed, kept in a vitiated atmosphere, and 
subjected to unfavorable hygienic conditions. Deformities are there- 
fore more common in them than in the more healthy children of 
the upper classes or of the rural population. The higher degrees of 
deformity, necessitating the Cesarean section or craniotomy, are in 
England of extreme rarity ; while in certain districts on the Con- 
tinent they seem to be so frequent that these ultimate resources of the 
obstetric art have to be constantly employed. 

In another class of cases the ordinary shape is modified by weight 
and counter-pressure operating on a pelvis in which one or more of 
the articulations is ossified. In this way w r e have produced the 
obliquely ovate pelvis of JSTaegele, or the still more uncommon trans- 
versely contracted pelvis of Robert. 

Other Causes of Pelvic Deformity. — A certain number of de- 
formed pelves cannot be referred to a modification of the ordinary 
developmental changes of the bones. Amongst these are the deform- 
ities resulting from spondylolisthesis, or downward dislocation of the 
lower lumbar vertebrae ; from displacements of the sacrum, caused by 
curvatures of the spinal column, producing the kyphotic and scoliotic 
pelves ; or from diseases of the pelvic bones themselves, such as 
tumors, malignant growths, and the like. 

The first class of deformeel pelves to be considered is that in which 
the diameters are altered from the usual standard, without any definite 
distortion, of the bones ; and such are often mere congenital variations 
in size, for which no definite explanation can be given. Of this class 
is the pelvis which is equally enlarged in all its diameters (pelvis 
wquabiliter justo major), which is of no obstetric consequence, except 
inasmuch as it may lead to precipitate labor, and is not likely to be 
diagnosed during life. 

The corresponding diminution of all the pelvic diameters (pelvis 
cequabiliter justo minor) may be met with in women who are apparently 
w r ell-formed in every respect, and whose external conformation and 
previous history give no indication of the abnormality. Sometimes 
the diminution amounts to half an inch or more, and it can readily be 
understood that such a lessening in the capacity of the pelvis would 
give rise to serious difficulty in labor. Thus, in three cases recorded 
by Naegele a fatal result followed ; in two after difficult instrumental 
delivery, and in the third after rupture of the uterus. The equally 
lessened pelvis, however, is of great rarity. An unusually small pelvis 
may be met with in connection with general small size, as in dwarfs. 
It does not necessarily follow, because a woman is a dwarf, that the 
pelvis is too small for parturition. On the contrary, many such 
women have borne children without difficulty. 

In some cases a pelvis retains its infantile characteristics after 
puberty (Fig. 134). The normal development of the pelvis has been 
interfered with, possibly from premature ossification of the different 
portions of the innominate bones, or from arrest of their growth from 
a weakly or rhachitic constitution. The measurements of these pelves 



DEFORMITIES OF THE PELVIS. 399 

are not always below the normal standard ; they may continue to 
grow, although they have not developed. The proportionate measure- 
ments of the various diameters will then be as in the infant ; and the 
antero-posterior diameter may be longer, or as long as the transverse, 
the ischia comparatively near each other, and the pubic arch narrow. 
Such a form of pelvis will interfere with the mechanism of delivery, 
and unusual difficulty in labor will be experienced. Difficulties from 
a similar cause may be expected in very young girls. Here, however, 
there is reason to hope that, as age advances, the pelvis will develop 
aud subsequent labors be more easy. 

Fig. 134. 




Adult pelvis retaining its infantile type. 

The masculine, or funnel-shaped, pelvis owes its name to its approxi- 
mation to the type of the male pelvis. The bones are thicker and 
stouter than usual, the conjugate diameter of the brim longer, and the 
whole cavity rendered deeper and narrower at its lower part by the 
nearness of the ischial tuberosities. It is generally met with in strong 
muscular women following laborious occupations, and Dr. Barnes, 
from his 'experience in the Royal Maternity charity, says that it chiefly 
occurs in weavers in the neighborhood of Bethnal Green, who spend 
most of their time in the sitting posture. 

a The cause of this form of pelvis seems to be an advanced condition 
of ossification in a pelvis which would otherwise have been infantile, 
brought about by the development of unusual muscularity, correspond- 
ing to the laborious employment of the individual/' The difficulties in 
labor will naturally be met with toward the outlet, where the funnel 
shape of the cavity is most apparent. 

Diminution of the antero-posterior diameter (c. v.) (flattened pelvis) 
is most frequently limited to the brim, and is by far the most common 
variety of pelvic deformity. In its slighter degrees it is not neces- 
sarily dependent on rickets, although when more marked it almost in- 
variably is so. When unconnected with rickets it probably can be 
traced to some injurious influence before the bones have ossified, such 



400 LABOR. 

as increased pressure of the trunk, from carrying weights in early 
childhood, and the like. By this means the sacrum is unduly depressed, 
and projects forward, so as to slightly narrow the conjugate diameter. 

Mode of Production in Rickets. — When caused by rickets the 
amount of the contraction varies greatly, sometimes being very slight, 
sometimes sufficient to prevent the passage of the child altogether, and 
necessitate craniotomy or the Cesarean section. The sacrum, softened 
by the disease, is pressed vertically downward by the weight of the 
body, its descent being partially resisted by the already ossified por- 
tions of the bone, so that the result is a downward and forward move- 
ment of the promontory. The upper portion of the sacral cavity is 

Fig. 135. 




Scolio-rhachitic pelvis. (From a specimen in the Museum of St. Bartholomew's Hospital.) 

thus directed more backward ; but, as the apex of the bone is drawn 
forward by the attachment of the perineal muscles to the coccyx, and 
by the sacro-ischiatic ligaments, a sharp curve of its lower part in a 
forward direction is established. The horizontal rami of the pubes 
are also flattened, while the ischia are more widely separated than in a 
normal pelvis, thus producing a greater width of the pubic arch, while 
the acetabula are turned forward. 

The depression of the sacral promontory would tend to produce 
strong traction, through the sacro-iliac ligaments, on the posterior end 
of the sacro-cotyloid beams, and thus induce expansion of the iliac 
bones, and consequent increase of the transverse diameter of the brim. 
So an unusual length of the transverse diameter (t) is very often de- 
scribed as accompanying this deformity, but probably it is not so often 
apparent as might otherwise be expected, on account of the imperfect 
development of the bones generally accompanying rickets ; and Barnes l 

1 Lectures on Obst. Operations, p. 280. 



DEFORMITIES OF THE PELVIS. 401 

says that in parts of London where deformities are most rife, any 
enlargement of the transverse diameter is exceedingly rare. 

Frequently the sacrum is not only depressed, but displaced more or 
less to one side, most generally to the left, thus interfering with the 
regular shape of the deformed brim. This is often the result of 
a lateral flexion of the spinal column, depending on the rhachitic 
diathesis, and when well marked is known as the scolio-rhachitic pelvis 
(Fig. 135), in which one side of the pelvis, that corresponding to the 
direction of the spinal curve, is asymmetrical and contracted, the ilio- 
pectineal line being sharply curved inward about the site of the sacro- 
iliac synchondrosis, the symphysis pubis being displaced toward the 
opposite side. A somewhat similar, but much less marked, unilateral 
asymmetry may exist in cases of scoliosis unconnected with rickets, 
but rarely to a sufficient degree to interfere materially with labor. 

In most cases of this kind the cavity of the pelvis is not diminished 
in size, and is often even more than usually wide. The constant 

Fig. 136. 




Rickety pelvis, with backward depression of symphysis pubis. 

pressure on the ischia, which the sitting posture of the child entails, 
tends to force them apart, and also to widen the pubic arch. Con- 
siderable advantage results from this in cases in which we have to 
perform obstetric operations, as it gives plenty of room for manipu- 
lation. 

Figure-of-eight Deformity. — In a few exceptional cases the nar- 
rowing of the conjugate diameter is increased by a backward depression 
of the symphysis pubis, which gives the pelvic brim a sort of figure- 
of-eight shape (Fig. 136). The most reasonable explanation of this 
peculiarity seems to be that it is the result of the muscular contraction 
of the recti muscles, at their point of attachment, when the centre of 
gravity of the body is thrown backward, on account of the projection 
of the sacral promontory. Sometimes also the antero-posterior diam- 
eter of the cavity is unusually lessened by the disappearance of the 
vertical curvature of the sacrum, which, instead of forming a distinct 
cavity, is nearly flat (Fig. 137). 

Spondylolisthesis. — In a few rare cases, to which attention was 
first called in 1853 by Kilian, of Bonn, a very formidable narrowing 
of the conjugate diameter of the pelvic brim is produced by a down- 
ward displacement of the fourth and fifth lumbar vertebrae, which 

26 



402 



LABOK, 



become dislocated forward, or, if not actually dislocated, at least separ- 
ated from their several articulations to a sufficient extent to encroach 
very seriously on the dimensions of the pelvic inlet. This condition 
is known as spondylolisthesis (Fig. 138). 



Fig. 137. 



Fig. 138. 





Flatness of sacrum, with narrowing of 
pelvic cavity. 



Pelvis deformed by spondylolisthesis. 
(After Kilian.) 



The effect of this is sufficiently obvious, for the projection of the 
lumbar vertebrae prevents the passage of the child. To such an extent 
is obstruction thus produced, that, in the majority of the recorded 
cases, the Cesarean section was necessary. The true conjugate diameter, 
that between the promontory of the sacrum and the symphysis pubis, 
is increased rather than diminished ; but, for all practical purposes, 
the condition is similar to extreme narrowing of the conjugate from 
rickets, for the bodies of the displaced vertebrae project into and ob- 
struct the pelvic brim. 

The cause of this deformity seems to be different in different cases. 
In some it seems to have been congenital, and in others to have de- 
pended on some antecedent disease of the bones, such as tuberculosis 
or scrofula, producing inflammation and softening of the connection 
between the last lumbar vertebra and the sacrum, thus permitting 
downward displacement of the bones. Lambl believed that it gener- 
ally followed spina bifida, which had besome partially cured, but 
which had produced deformity of the vertebrae, and favored their dis- 
location. Brodhurst, 1 on the other hand, thinks that it most probably 
depends on rhachitic inflammation and softening of the osseous and 
ligamentous structures, and that it is not a dislocation in the strict sense 
of the word. This condition has recently been made the subject of 
special study by Dr. Frangois Neugebauer, 2 who believes that the for- 
ward displacement is never the result of antecedent disease of the 
bones, but depends either on congenital want of development of the 



1 Obst. Trans., vol. vi. p. 97. 

2 Contribution k la Pathogenie du Bassin vicie par le Glissenient Vertebral. Paris, 1884. 



DEFORMITIES OF THE PELVIS. 403 

vertebral arches, or on traumatism, such as fracture of the articular 
processes, which allows the weight of the trunk to displace the body of 
the last lumbar vertebra forward, either partially or entirely. 

Spondylolizema. — A somewhat analogous deformity has been 
described by Hergott l under the name of Spondylolizema. In this the 
bodies of the lower lumbar vertebrae having been destroyed by caries, 
the upper lumbar vertebra? sink downward and forward, so as to 
obstruct the pelvic inlet and prevent the engagement of the foetus. 
It thus differs from spondylolisthesis, in which there is dislocation, 
but not destruction, of the bodies of the lower lumbar vertebra?. 

Deformity from Osteomalacia. — The most marked examples of 
narrowing of both oblique diameters depend on osteomalacia. In this 
disease, as has already been remarked, the bones are uniformly softened, 
and the alterations in form are further influenced by the fact that the 
disease commences after union of the separate portions of the ossa 
innominata has been completely effected. The amount of deformity 
in the worst cases is very great, and frequently renders delivery im- 
possible without the Cesarean section. Sometimes the softening of 
the bones proves of service in delivery by admitting of the dilatation 
of the contracted pelvic diameter by the pressure of the presenting 
part, or even by the hand. Some curious cases are on record in which 
the deformity was so great as to apparently require the Cesarean sec- 
tion, but in which the softened bones eventually yielded sufficiently to 
render this unnecessary. 

The weight of the body depresses the sacrum in a vertical direction, 
and at the same time compresses its component parts together, so as to 
approximate the base and apex of the bone, and narrow the conjugate 
diameter of the brim, by causing the promontory to encroach upon it* 

Fig. 139. 




Osteomalacic pelvis. 



The most characteristic changes are produced by the pushing inward 
of the walls of the pelvis at the cotyloid cavities, in consequence of 



* Arch, de Tocologie, 1877, p. 65. 



404 LABOR. 

pressure exerted at these points through the femora. The effect of this 
is to diminish both oblique diameters, giving the brim somewhat the 
shape of a trefoil, or an ace of clubs. The sides of the pubes are at 

Fig. 140. 




Extreme degree of osteomalacic deformity. 

the same time approximated, and may become almost parallel, and the 
true conjugate may be even lengthened (Fig. 139). The tuberosities 
of the ischia are also compressed together, with the rest of the lateral 
pelvic wall, so that the outlet is greatly deformed as well as the brim. 
(Fig;. 140). 

Obliquely Contracted Pelvis. — That form of deformity in which 
one oblique diameter only is lessened has received considerable atten- 
tion, from having been made the subject of special study by Naegele, 
and is generally known as the obliquely contracted pelvis (Fig. 141). It 
is a condition that is very rarely met with, although it is interesting 
from an obstetric point of view, as throwing considerable light on the 
mode in which the natural development of the pelvis is effected. It is 
difficult to diagnose, inasmuch as there is no apparent external de- 
formity, and probably it has never, in fact, been detected before 
delivery. It has a very serious influence on labor ; Litzmann found 
that out of twenty-eight cases of this deformity, twenty-two died in 
their labors, and five more in subsequent deliveries. The prognosis, 
therefore, is very formidable, and renders a knowledge of this distor- 
tion, rare though it be, of importance. 

Its essential characteristic is flattening and want of development of 
one side of the pelvis, associated with ankylosis of the corresponding 
sacro-iliac synchondrosis. The latter is probably always present, and 
it seems to be most generally a congenital malformation. The lateral 
half of the sacrum on the same side, and the entire innominate bone, 
are much atrophied. The promontory of the sacrum is directed toward 
the diseased side, and the symphysis pubis is pushed over toward the 
healthy side. 

The main agent in the production of this deformity is the absence of 
the sacro-iliac joint, which prevents the proper lateral expansion of the 
pelvic brim on that side, and allows the counter-pressure through the 
femur to push in the atrophied os innominatum to a much greater ex- 



DEFORMITIES OF THE PELVIS. 



405 



tent than usual. The chief diminution in the length of the pelvic 
diameter is between the ilio-pectineal eminence of the affected side and 
the healthy sacro-iliac joint ; while the oblique diameter betweeu the 
ankylosed joint and the healthy os innominatum is of normal length. 

Narrowing- of the Transverse Diameter. — Transverse contraction 
of the pelvic brim is very much less common than narrowing of the 
conjugate diameter. It most frequently depends on backward curva- 
ture of the lower parts of the spinal column, in consequeuce of disease 
of the vertebra?. This form of deformed pelvis is generally known as 
the kyphotic (Fig. 142). The effect of the spinal curvature is to drag 
the promontory of the sacrum backward, so that it is high up and out 
of reach. By this means the antero-posterior diameter of the brim is 
increased, while the transverse is lessened; the relative proportion 
between the two is thus reversed. While the upper portion of the 
sacrum is displaced backward, its lower end is projected forward, so 



Fig. 141. 



Fig. 142. 




Robert's, or double obliquely contracted 
pelvis. (After Dukcah.) 



Kyphotic pelvis. (From a specimen in the Museum 
of St. Bartholomew's Hospital.) 



that the antero-posterior diameters of the cavity and outlet are con- 
siderably diminished. The ischial tuberosities are also nearer to each 
other, and the pubic arch is narrowed. Obstruction to delivery will 
be chiefly met with at the lower parts and outlet of the pelvic cavity ; 
for, although the transverse diameter of the brim is narrowed, there is 
generally sufficient space for the passage of the head. 



406 



LABOR. 



Robert's Pelvis. — Another form of transversely contracted pelvis 
is known as Robert's pelvis (Fig. 143), having been first discovered 
by Robert, of Coblentz. It is in fact a double obliquely contracted 
pelvis, depending on ankylosis of both sacro-iliac joints, and conse- 
quent defective development of the innominate bones. The shape of 
the pelvic brim is markedly oblong, and the sides of the pelvis are 
more or less parallel with each other. The outlet is also much con- 
tracted transversely. The amount of obstruction is very great, so that, 
according to Schroeder, out of seven well-authenticated cases, the 
Csesarean section was required in six. 

Deformity from Old-standing" Hip-joint Disease. — Another cause 
of transverse deformity occasionally met with is luxation of the head 
of the femur, depending on old-standing joint disease. The head of 
the femur, in this case, presses on the innominate bone at the site of 
dislocation, and the result is that the iliac fossa on the aifected side, or 
both if the accident happens on both sides, is pushed inward, the 
transverse diameter of the brim being lessened. The tuberosity of 
the ischium is, ho ver, projected outward, so that the outlet of the 
pelvis is increased rather than diminished. 

Deformity from Tumors, Fractures, etc. — Obstruction of the 
pelvic cavity from exostoses or other forms of tumors growing from 
the bones is of great rarity (Fig. 144). It may, however, produce 
very serious dystocia. Several curious examples are collected in Mr. 

Wood's article on the pelvis, in some 
of which the obstruction w r as so great 
as to necessitate the Csesarean section. 
Some of these growths were true 
exostoses, and according to Stad- 
feldt, these are commonly found in 
pelves that are otherwise contracted ; 
others, osteo-sarcomatous tumors at- 
tached to the pelvic bones, most 
generally the upper part of the 
sacrum ; and others were malignant. 
In some cases spiculse of bone have 
developed about the linea ilio-pec- 
tinea or other parts of the pelvis, 
which may not be sufficient to pro- 
duce obstruction, but which may 
injure the uterus, or even the foetal 
head, when they are pressed upon 
them. Irregular projections may 
also arise from the callus of old 
fractures of the pelvic bones. All 
such cases defy classification and differ so greatly in their extent, and 
in their effect on labor, that no rules can be laid down for them, and 
each must be treated on its own merits. 

The effects of pelvic contractions on labor vary, of course, 
greatly with the amount and nature of the deformity ; but they must 
always give rise to anxiety, and in the graver degrees they produce 



Fig. 144. 




Bony growth from sacrum obstructing the 
pelvic cavity. 



DEFORMITIES OF THE PELVIS. 407 

the most serious difficulties we have to coutend with in the whole 
range of obstetrics. 

In the lesser degrees, in which the proportion between the present- 
ing part and the pelvis is only slightly altered, we may observe little 
abnormal beyond a greater intensity of the pains, and some protraction 
of the labor. It is generally observed that the uterine contractions 
are strong and forcible in cases of this kind, probably because of the 
increased resistance they have to contend against ; and this is obviously 
a desirable and conservative occurrence, which may, of itself, suffice 
to overcome the difficulty. The first stage, hoAvever, is not unfre- 
quently prolonged, and the pains are ineffective, for the head does not 
readily engage in the brim, the uterus is more mobile than in ordinary 
labors, and it probably acts at a disadvantage. 

Risk to the Mother. — In the more serious cases, the mother is 
subjected to many risks, directly proportionate to the amount of 
obstruction and the length of the labor. The long-continued and 
excessive uterine action, produced by the vain endeavors to push the 
child through the contracted pelvic canal, the more or less prolonged 
contusion and injury to which the maternal soft parts are necessarily 
subjected (not ^infrequently ending in inflammation and sloughing 
with all its attendant dangers), and the direct injury which may be 
inflicted by the measures we are compelled to adopt for aiding delivery 
(such as the forceps, turning, craniotomy, or Cesarean section), all 
tend to make the prognosis a matter of grave anxiety. 

Risk to the Child. — Nor are the dangers less to the child ; and a 
very large proportion of stillbirths will always be met with. The 
infantile mortality may be traced to a variety of causes, the most 
important being the protraction of the labor, and the continuous 
pressure to which the presenting part is subjected. For this reason, 
even in cases in which the contraction is so slight that the labor is 
terminated by the natural powers, it has been estimated that one out 
of every five children is stillborn ; and as the deformity increases in 
amount, so, of course, does the prognosis to the child become more 
unfavorable. 

Prolapse of the umbilical cord is of very frequent occurrence 
in cases of pelvic deformity, the tendency to this accident being trace- 
able to the fact of the head not entering and occupying the upper 
strait of the pelvis as in ordinary labors, and thus leaving a space 
through which the cord may descend. So frequently is this compli- 
cation met with in pelvic deformity that Stanesco found it had 
happened as often as fifty-nine times in 414 labors; and when the 
dangers of prolapsed funis are added to those of protracted labors, it 
is hardly a matter of surprise that the occurrence should, under such 
circumstances, almost always prove fatal to the child. 

The head of the child is also liable to injury of a more or less grave 
character, from the compression to which it is subjected, especially by 
the promontory of the sacrum. Independently of the transient effects 
of undue pressure (temporary alteration of the shape of the bones and 
bruising of the scalp), there is often met with a more serious depression 
of the bones of the skull, produced by the sacral promontory, in cases 



408 LABOR. 

in which the brim is contracted. This is most marked in cases in 
which the head has been forcibly dragged past the projecting bone by 
the forceps, or after turning. The amount of depression varies with 
the degree of contraction ; but sometimes, were it not for the yielding 
of the bones of the foetal skull in this way, delivery, without lessening 
the size of the head by perforation, would be impossible. Such de- 
pressions are found at the spot immediately opposite the promontory, 
generally at the side of the skull near the junction of the frontal and 
parietal bones. Sometimes there is a slight permanent mark, but more 
often the depression disappears in a few days. The prognosis to the 
child is, however, grave, when the contraction has been sufficient to 
indent the skull ; for it has been found that 50 per cent, of the chil- 
dren thus marked died either immediately or shortly after labor. In 
cases of generally contracted pelvis the pressure changes observed after 
delivery in the foetal head are similar to those occurring after normal 
labor, but they exist in a very exaggerated degree. The head is often 
much elongated and moulded into a conical shape, and the caput suc- 
cedaneum is very large. 

Course of Labor. — The means which Nature takes to overcome 
these difficulties are well worthy of study, and there are certain pecu- 
liarities in the mechanism of delivery, when pelvic deformities exist, 
which it is of importance to understand, as they guide us in deter- 
mining the proper treatment to adopt. 

Frequency of Malpresentation. — Malpresentations of the foetus 
are of much more frequent occurrence than in ordinary labors ; partly 
because the head does not engage readily in the brim, but, remaining 
free above it, is apt to be pushed away by the uterine contractions, and 
partly because of the frequent alteration of the axis of the uterine 
tumor. The pendulous condition of the abdomen in cases of pelvic 
deformity is often very obvious, so that the fundus is sometimes 
almost in a line with the cervix, and thus transverse or other abnormal 
positions are very frequently met with. It is to be noted, however, 
that we cannot regard breech presentations as so unfavorable as in 
ordinary labors, for the pressure from the contracted pelvis is less 
likely to be injurious when applied to the body than to the head of 
the child ; and, indeed, as we shall presently see, the artificial pro- 
duction of these presentations is often advisable as a matter of choice. 

Mechanism of Delivery in Head Presentations. — The mode in 
which the head passes naturally through a contracted pelvis is in some 
respects different from the ordinary mechanism of delivery in head 
presentations, and has been carefully worked out by Spiegelberg and 
other German obstetricians. 

The means which Nature adopts to overcome the difficulty are 
different in cases in which there is a marked narrowing of the con- 
jugate diameter of the brim, and in those in which there is a generally 
contracted pelvis. 

a. In Contracted Brim. — In the former, and more common, de- 
formity, the head lies at the brim with its long occipito-frontal diameter 
in the transverse diameter of the pelvis, and, as both parietal bones 
cannot enter the contracted brim, it lies with one parietal bone on 



DEFORMITIES OF THE PELVIS. 



409 



Fig. 145. 




Head passing through the inlet in 
a flat pelvis. (After Parvin.) 



a much lower level than the other; in the large majority of cases 
that nearest the pubes being most depressed, so that the sagittal suture 
is felt high up near the promontory of the sacrum (Fig. 145). As 
labor advances, if the contraction is not too 
great to be insuperable, the anterior fonta- 
nelle comes much more within reach than 
in ordinary labor, while, at the same time, 
the occipital portion of the head is shoved 
to the side of the pelvis, so that its narrow 
bi-temporal diameter engages in the con- 
tracted conjugate. At this stage, on exami- 
nation, it will be found — supposing we have 
to do with a case in which the occiput points 
to the left side of the pelvis — that the 
anterior fontanelle is lower than the pos- 
terior, and to the right, that the bi-temporal 
diameter of the head is engaged in the con- 
jugate diameter of the brim (as the smallest 
diameter of the skull, there is manifest 
advantage in this), and that the bi- parietal 
diameter and the largest portion of the head 
points to the left side. The sagittal suture 

will be felt running across in the transverse diameter of the brim, but 
nearer to the sacrum, the head being placed obliquely. As the head 
is forced down by the uterine contractions, the parietal bone, which is 
resting on the promontory, is pushed against it, so that the sagittal 
suture is forced more into the true transverse diameter of the pelvic 
brim, and ap]} roaches nearer to the pubes. The next step is the 
depression of the head, the occiput undergoing a sort of rotation on 
its transverse axis so that it reaches a plane below the brim. When 
this is accomplished, the rest of the head readily passes the obstruction. 
The forehead now meets with the resistance of the pelvic walls, the 
posterior fontanelle descends to a lower level, 
and, as the cavity of the pelvis in cases of 
antero-posterior contraction of the brim is 
generally of normal dimensions, the rest of 
the labor is terminated in the usual way. 

b. In Generally Contracted Pelvis. — In 
the generally contracted pelvis the head enters 
the brim with the posterior fontanelle lowest, 
and it is after it has engaged in it that the 
resistance to its progress becomes manifest. 
The result is, therefore, an exaggeration of 
what is met with in ordinary eases. The 
resistance to the anterior or longer arm of 
the lever is greater than that to the occipital 
or shorter ; and, therefore, the flexion of 
the head becomes very marked (Fig. 146). 
The posterior fontanelle is consequently unusually depressed, and the 
anterior quite out of reach. So the head is forced down as a wedge, 



Fig. 146. 




Marked flexion of the head 
entering a generally contracted 
pelvis. (After Pauvin.) 



410 LABOR. 

and its further progress must depend upon the amount of contraction. 
If this be not too great the anterior fontanelle eventually descends, 
and delivery is completed in the usual way. Should the contraction 
be too much to permit of this, the head becomes jammed in the pelvis, 
and diminution of its size may be essential. 

In cases of deformity of the conjugate diameter combined with 
general contraction of the pelvis, the mechanism partakes of the pecu- 
liarities of both these classes, to a greater or less extent, in proportion 
to the preponderance of one or other species of deformity. 

Diagnosis. — It rarely happens that deformities of the pelvis, except 
of the gravest kind, are suspected before labor has actually commenced, 
and therefore we are not often called upon to give an opinion as to 
the condition of the pelvis before delivery. Should we be so, there 
are various circumstances which may aid us in arriving at a correct 
conclusion. Prominent among them is the history of the patient in 
childhood. If she is known to have suffered from rickets in early 
life, more especially if the disease has left evident traces in deformities 
of the limbs, or in a dwarfed and stunted growth, or in curvature of 
the spine, there will be strong presumptive evidence of pelvic deformity; 
a markedly pendulous state of the abdomen may also tend to confirm 
the suspicion. Nothing short of a careful examination of the pelvis 
itself will, however, clear up the point with certainty ; and even by 
this means, to estimate the precise degree of deformity with accuracy 
requires considerable skill and practice. The ingenuity of practitioners 
has been much exercised — it might perhaps be justly said wasted — in 
the invention of various more or less complicated pelvimeters for aid- 
ing us in obtaining the desired object. It is, however, pretty generally 
admitted by all accoucheurs that the hand forms the best and most 
reliable instrument for this purpose, at any rate as regards the interior 
of the pelvis ; although a pair of callipers, such as Baudelocque's well- 
known instrument, is essential for accurately determining the external 
measurements. The objections to all internal pelvimeters, even those 
most simple in their construction, are their cost and complexity, and 
the impossibility of using them without pain or injury to the patient. 

It was formerly thought that by measuring the distance between the 
spinous processes of the sacrum and the symphysis pubis, and sub- 
tracting from it what we judge to be the thickness of the bones and 
soft parts, we might arrive at an approximate estimate of the measure- 
ment of the conjugate diameter of the pelvic brim. It is now admitted 
that this method can never be depended on, and that, taken by itself, 
it is practically useless. A change in the relative length of other ex- 
ternal measurements of the pelvis is, however, often of great value in 
showing the existence of deformity internally, although not in judging 
of its amount. The measurements which are used for this purpose are 
between the anterior superior spines of the ilia, and between the centres 
of their crests, averaging respectivelv ten and one-quarter and eleven 
and one-quarter inches in the covered pelvis. It is to be noted, how- 
ever, that these measurements vary considerably in different women, 
and, per se 9 their actual length, unless greatly under the average, is of 



DEFORMITIES OF THE PELVIS. 411 

little value. Relatively, according to Spiegelberg, they may give one 
of three results: 

1. Both may be less than they ought to be, but the relation of one 
to the other remains unchanged. 

2. That between the crests is not, or is at most very little, dimin- 
ished, but that between the spines is increased. 

3. Both are diminished, but at the same time their mutual relation is 
not normal, the distance between the spines being as long, if not longer, 
than that between the crests. 

Xo. 1 denotes a uniformly contracted pelvis ; No. 2, a pelvis simply 
contracted in the conjugate diameter of the brim, and not otherwise 
deformed; Xo. 3, a pelvis with narrowed conjugate and also uniformly 
contracted, as in the severe type of rhachitic deformity. If, however, 
both these measurements are of average length, and the distance be- 
tween the crests is about one inch greater than between the spines, the 
pelvis is normal. 

Besides the above, useful information may be obtained by the meas- 
urement of the external conjugate diameter, which averages seven and 
three-quarters inches, varying somewhat with the amount of adipose 

Fig. 147. 




Pelvimeter. 



tissue present. This may be taken by placing one point of the 
callipers in the depression below the spine of the last lumbar ver- 
tebra, the other at the centre of the upper edge of the symphysis 
pubis. The former position can be found by drawing a straight line 
between the posterior-superior spinous process of the ilia, the spinous 
process above that being that of the last lumbar vertebra. If the meas- 
urement be distinctly below the average, not more, for example, than 
six and one-quarter inches, we may conclude that there is a consider- 
able narrowing of the antero-posterior diameter of the brim, the extent 
of which we must endeavor to ascertain by other means. If, on the 
other hand, the measurement equals or exceeds the average (seven and 
one-half to eight and one-half inches), such contraction may be ex- 
cluded. If we find all these external measurements to be normal both 
as to length and relation, then we may safely conclude that the pelvis 
also is normal, and no further examination is required. 

For the purpose of making these measurements, Baudelocque's 



412 



LABOR 



compas d'epaisseur can be used (Fig. 147), or Dr. Lazarewitch's elegant 
universal pelvimeter, which cau be adopted also for internal pelvim- 
etry ; but, in the absence of these special contrivances, an ordinary 
pair of callipers, such as are used by carpenters, can be made to answer 
the desired object. 

These external measurements must be corroborated, when abnormal, 
by internal, chiefly of the antero-posterior diameter, by which alone 
we can estimate the amount of the deformity. We endeavor to find, 
in the first place, the length of the inclined conjugate, between the 
lower edge of the symphysis pubis and the promontory of the sacrum, 
which averages about half an inch more than the true conjugate. This 
is best clone by placing the patient on her back, with the hips well 
raised. The index and middle fingers of the right hand are then in- 
troduced into the vagina, and the perineum is pressed steadily back- 
ward, so as to overcome the resistance it offers. The tip of the middle 
finger is passed steadily upward until it reaches the promontory of the 
sacrum, which is recognized by the breadth of the cartilage between it 
and the last lumbar vertebra. Care must be taken not to mistake the 
junction between the first and second sacral vertebras, occasionally 

Fig. 148. 




Greenhalgh's pelvimeter. 

unduly prominent, for the true promontory. If the tip of the finger 
can reach the promontory of the sacrum, the radial side of the hand is 
raised so as to touch the lower edge of the pubes. A mark is made 
with the nail of the index of the left hand on that part of the index 
finger of the right hand which rests under the symphysis, and then the 
distance from this to the tip of the finger, less one-half to three-quarters 
of an inch, may be taken to indicate the measurement of the true con- 
jugate of the brim. Various pelvimeters have been devised to make 



DEFORMITIES OF THE PELVIS. 413 

the same measurements, such as Lumlev Earle's, Lazarewitch's, which 
is similar in principle, and Van Huevel's ; the best and simplest, I 
think, is that invented by Dr. Greenhalgh (Fig. 148). It consists 
of a movable rod, attached to a flexible band of metal which passes 
around the palm of the examining hand. At the distal end of the rod 
is a curved portion, which passes over the radial edge of the index 
finger. The examination is made in the usual way, and when the 
point of the finger is resting on the promontory of the sacrum, the rod 
is withdrawn until it is arrested by the posterior surface of the sym- 
physis, the exact measurement of the inclined conjugate being then 
read oif the scale. 

It is to be remembered that this procedure is useless in the slighter 
degrees of contraction, in which the promontory of the sacrum cannot 
be easily reached. Dr. Ramsbotham proposed to measure the conju- 
gate by spreading out the index and middle fingers internally, the tip 
of one resting on the promontory, the other behind the symphysis 
pubis ; and then withdrawing them, in the same position, and meas- 
uring the distance between them. This manoeuvre I believe to be 
impracticable. 

Whenever, in actual labor, we wish to ascertain the condition of 
the pelvis accurately, the patient should be anaesthetized, and the 
whole hand introduced into the vagina (which could not otherwise be 
done without causing great pain), and the proportions of the pelvis, 
and the relations of the head to it, thoroughly explored ; and, if what 
has been said as to the mechanism of delivery in these cases be borne 
in mind, this may aid us in determining the kind of deformity exist- 
ing. In this way contractions about the outlet of the pelvis can also 
be pretty generally made out. 

The obliquely contracted pelvis cannot be determined by any of 
these methods, but certain external measurements, as iNaegele has 
pointed out, will readily enable us to recognize its existence. It will 
be found that measurements which in the healthy pelvis ought to be 
equal are unequal in the obliquely distorted pelvis. The points of 
measurement are chiefly : 1. From the tuberosity of the ischium on 
one side to the posterior superior spine of the ilium on the other. 2. 
From the anterior superior iliac spine on the one side to the posterior 
superior on the opposite. 3. From the trochanter major of one side 
to the posterior superior iliac spine on the other. 4. From the lower 
edge of the symphysis pubis to the posterior superior iliac spine on 
either side. 5. From the spinous process of the last lumbar vertebra 
to the anterior superior spine of the ilium on either side. 

If these measurements differ from each other by half an inch to an 
inch, the existence of an obliquely deformed pelvis may be safely 
diagnosed. The diagnosis can be corroborated by placing the patient 
in the erect position, and letting fall two plumb-lines, one from the 
spines of the sacrum, the other from the symphysis pubis. In a 
healthy pelvis these will fall in the same plane, but in the oblique 
pelvis the anterior line will deviate considerably toward the unaffected 
side. 

Treatment. — The proper management of labor in contracted pelvis 



414 LABOR. 

is, even up to this time, one of the most vexed questions in midwifery, 
notwithstanding the immense amount of discussion to which it has 
given rise ; and the varying opinions of accoucheurs of equal experi- 
ence afford a strong proof of the difficulties surrounding the subject. 
This remark applies, of course, only to the lesser degree of deformity, 
in which the birth of a living child is not hopeless. When the antero- 
posterior diameter of the brim measures from two and three-quarters 
to three inches, it is universally admitted that the destruction of the 
child is inevitable, unless the pelvis be so small as to necessitate the 
performance of the Cesarean section. But when it is between three 
inches and the normal measurement, the comparative merits of the 
forceps, turning, and the induction of premature labor form a fruitful 
theme for discussion. With one class of accoucheurs the forceps is 
chiefly advocated, and turning admitted as an occasional resource when 
it has failed; and this, indeed, speaking broadly, may be said to 
have been the general view held in England. More recently we find 
German authorities of eminence, such as Schroeder and Spiegelberg, 
giving turning the chief place, and condemning the forceps altogether 
in contracted pelves, or at least restricting its use within very narrow 
limits. More strangely still Ave find, of late, that the induction of 
premature labor, on the origination and extension of which British 
accoucheurs have always prided themselves, is placed without the pale, 
and spoken of as injurious and useless in reference to pelvic deformi- 
ties. To see our way clearly amongst so many conflicting opinions is 
by no means an easy task, and perhaps we may best aid in its accom- 
plishment by considering separately the three operations in so far as 
they bear on this subject, and pointing out briefly what can be said 
for and against each of them. 

The Forceps. — In England and in France it is pretty generally 
admitted that in the slighter degrees of contraction the most reliable 
means of aiding the patient is by the forceps. It should be remem- 
bered that the operation, under such circumstances, is always much 
more serious than in ordinary labors simply delayed from uterine 
inertia, when there is ample room, and the head is in the cavity of 
the pelvis ; for the blades have to be passed up very high, often when 
the head is more or less movable above the brim, and much more 
traction is likely to be required. For these reasons artificial assist- 
ance, when pelvic deformity is suspected, is not to be lightly or hur- 
riedly resorted to. Nor, fortunately, is it always necessary, for if the 
pains be sufficiently strong, and the contraction not too great to pre- 
vent the head engaging at all, after a lapse of time it will become so 
moulded in the brim as to pass even a considerable obstruction. In 
all cases, therefore, sufficient time must be given for this ; and if no 
suspicious symptoms exist on the part of the mother — no elevation of 
temperature, dryness of the vagina, rapid pulse, and the like, and the 
foetal heart sounds continue to be normal — labor may be allowed to 
go on for some hours after the rupture of the membranes, so as to give 
Nature a chance of completing the delivery. When this seems hope- 
less, the intervention of art is called for. 

The forceps is generally considered to be applicable in all degrees 



DEFORMITIES OF THE PELVIS. 415 

of contraction, from the standard measurement down to about three 
and a quarter inches in the conjugate of the brim. There can be no 
doubt that in such cases traction with the forceps often enables us to 
effect delivery, when the natural efforts have proved insufficient, and 
holds out a very fair hope of saving the child. Out of seventeen 
cases in which the high forceps operation was resorted to for pelvic 
deformity, reported by Stanesco, in thirteen living children were born. 
If the length of the labor, and the long-continued compression to 
which the child has been subjected, be borne in mind, this result must 
be considered very favorable. 

What are the objections which have been brought against the opera- 
tion? These have been principally made by Schroeder and other 
German writers. They are, chiefly, the difficulty of passing the in- 
strument ; the risk of injuring the maternal structures ; and the sup- 
position that, as the blades must seize the head by the forehead and 
occiput, their compressive action will diminish its longitudinal and 
increase its transverse diameter (which is opposed to the contracted 
part of the brim), and so enlarge the head just where it ought to be 
smallest. There is little doubt that these writers much exaggerate 
the compressive power of the forceps. Certainly, with those generally 
used in this country, any disadvantage likely to accrue from this is 
more than counterbalanced by the traction on the head ; and the fact 
that minor degrees of obstruction can be thus overcome, with safety 
both to the mother and child, is abundantly proved by the numberless 
cases in which the forceps has been used. 

It is very likely that the forceps does not act equally well in all 
cases. When the head is loose above the brim ; when the contraction 
is chiefly limited to the antero-posterior diameter, and there is abun- 
dance of room at the sides of the pelvis for the occiput to occupy after 
version ; and when, as is usual in these cases, the anterior fontanelle 
is depressed and the head lies transversely across the brim, turning is 
certainly the safer operation for the mother, and the easier performed. 
When, on the other hand, the head has engaged in the brim, and has 
become more or less impacted, it is obvious that version could not be 
performed without pushing it back, which may be neither easy nor 
safe. In the generally contracted pelvis, in which the head enters in 
an exaggerated state of flexion and lies obliquely, the posterior 
fontanelle being much depressed, the forceps is more suitable. 

Mechanical Advantage of Turning- in Certain Cases. — The 
special reasons why version sometimes succeeds when the forceps fails, 
or why it may be elected from the first as a matter of choice, have 
been by no one better pointed out than by Sir James Simpson. 
Although the operation was performed by many of the older obstetri- 
cians, its revival in modern times, and the clear enunciation of its 
principles, can undoubtedly be traced to his writings. He points out 
that the head of the child is shaped like a cone, its narrowest portion 
the base of the cranium (Fig. 149, b b), measuring, on an average, from 
one-half to three-quarters of an inch less than the broadest portion 
(Fig. 149, a a), viz., the bi-parietal diameter. In ordinary head pres- 
entations the latter part of the head has to pass first ; but if the feet 



416 



LABOR, 



are brought down, the narrow apex of the cranial cone is brought first 
into apposition with the contracted brim, and can be more easily drawn 
through than the broader base can be pushed through by the uterine 
contractions. Nor is this the only advantage, for, after turning, the 
narrower bi-temporal diameter (Fig. 150, b b) — which measures, on an 
average, half an inch less than the bi-parietal (Fig. 150, a a) — is brought 
into contact with the contracted conjugate, while the broader bi-parietal 
lies in the comparatively wide space at the side of the pelvis (Fig. 151). 
These mechanical considerations are sufficiently obvious, and fully 
explain the success which has often attended the performance of the 
operation. 

Fig. 150. 



Fig. 149, 





Section of foetal cranium, showing 
its conical form. 



Showing the greater breadth of the 
bi-parietal diameter of the foetal 
cranium. (After Simpson.) 



Fig. 151. 




Showing the greater space for the bi-parietal diameter at the side of the pelvis in certain 
cases of deformity. (After Simpson.) 



It is generally admitted that it may be possible, for the reasons just 
mentioned, to deliver a living child by turning through a pelvis con- 
tracted beyond the point which would permit of a living child being 
extracted by the forceps. Many obstetricians believe that it is possible 
to deliver a living child by turning in a pelvis contracted even to the 
extent of two and three-quarters inches in the conjugate diameter. 
Barnes maintains that, although an unusually compressible head may 
be drawn through a pelvis contracted to three inches, the chance of 
the child being born alive under such circumstances must necessarily 
be small, and that from three and a quarter inches to the normal size 
must be taken as the proper limits of the operation. The modem 



DEFORMITIES OF THE PELVIS. 417 

French school of obstetricians teach that in cases of this type the proper 
practice is first to widen the pelvis by symphysiotomy, and then to 
apply the forceps. The contention is that the results as regards the 
infaut are much more satisfactory than after turning. This practice 
lias never been followed in England, where symphysiotomy has been 
little practised, and only as an alternative to craniotomy, not to tarniug. 1 

That delivery is often possible by turning, after the forceps and the 
natural powers have failed, and when no other resource is left but the 
destruction of the child, must, I think, be admitted by all ; for the 
records of obstetrics are full of such cases. To take one example 
only, Dr, Braxton Hicks 2 records four cases in which the forceps was 
tried unsuccessfully, in all of which version was used, three of the 
children being born alive. Here are the lives of three children rescued 
from destruction, within a short period, in the practice of one man ; 
and a fact like this would of itself be ample justification of the attempt 
to deliver by turning, when the child was known to be alive, and 
other means had tailed. The possibility that craniotomy may still be 
required is no argument against the operation ; for although perfora- 
tion of the after-coming head is certainly not so easy as perforation of 
a presenting head, it is not so much more difficult as to justify the 
neglect of an experiment by which it may possibly be altogether 
avoided. 

The original choice of turning is a more difficult question to decide. 
The most generally received opinion in the present day among scientific 
obstetricians is that in the simply flattened pelvis, with an antero- 
posterior diameter of not less than two and three-quarters inches, turn- 
ing is the preferable operation. In every case of doubt it is desirable 
thoroughly to anaesthetize the patient and make a careful examination 
with the whole hand in the vagina. If we find the sagittal suture 
lying transversely, one parietal bone on a lower line than the other, 
and if both fontaneiles are easily within reach, and some space exists 
at the sides of the pelvis beside the forehead and occiput, then turning 
is the procedure most likely to succeed, and the descent of the head 
after version can be very materially assisted by strong pressure applied 
from above by an assistant, as has been well pointed out by Goodell. 3 
If, on the other hand, the anterior fontanelle is high up, and out of 
reach, the head being distinctly flexed, we have to do with a generally 
contracted pelvis, and the forceps is the preferable operation. 

When the contraction is below three inches in the conjugate, or 
when the forceps or turning has failed, no resource is left but symphys- 
iotomy, the destruction of the foetus, or the Cesarean section. 

The Induction of Premature Labor. — The induction of premature 
labor as a means of avoiding the risk of delivery at term, and of 
possibly saving the life of the child, must now be studied. The estab- 
lished rule in England is, that in all cases of pelvic deformity the 
existence of which has been ascertained either by the experience of 

1 See Varnier: "De 1'application du forceps au detroit superieur rutreci," etc. Annal de Gyn., 
vol. xxxix. p 345. 
- Guy's Hospital Reports, vol xv. 3d scr. p. 501. 
3 Amer. Jouru. of Obstet., vol. viii. p. 193. 

27 



418 LABOR. 

former labors or by accurate examination of the pelvis, labor should 
be induced previous to the full period, so that the smaller and more 
compressible head of the premature foetus may pass where that of the 
foetus at term could not. The gain is a double one, partly the lessened 
risk to the mother, and partly the chance of saving the child's life. 

The practice is so thoroughly recognized as a conservative and 
judicious one that it might be deemed unnecessary to argue in its 
favor, were it not that some eminent authorities have of late years 
tried to show that it is better and safer to the mother to leave the 
labor to come on at term ; and that the risk to the child is so great in 
artificially induced labor as to lead to the conclusion that the opera- 
tion should be altogether abandoned, except, perhaps, in the extreme 
distortion in which the Cesarean section might otherwise be necessary. 
Prominent amongst those who hold these views are Spiegelberg and 
Litzmann, and they have been supported, in a modified form, by, 
Matthews Duncan. Spiegelberg tries to show, by a collection of 
cases from various sources, that the results of induced labor in con- 
tracted pelves are much more unfavorable than when the cases are left 
to Nature ; that in the latter the mortality of the mothers is 6.6 per 
cent., and of the children 28.7 per cent., whereas in the former the 
maternal deaths are 15 per cent, and the infantile 66.9 per cent. 
Litzmann arrives at not very dissimilar results — namely, 6.9 per cent, 
of the mothers and 20.3 per cent, of the children in contracted pelvis 
at term, and 14.7 per cent, of the mothers and 55.8 per cent, of the 
children, in artificially induced premature labor. 

If these statistics were reliable, inasmuch as they show a very 
decided risk to the mother, there might be great force in the argument 
that it would be better to leave the cases to run the chance of delivery 
at term. It is, however, very questionable whether they can be taken,, 
in themselves, as being sufficient to settle the question. The fallacy 
of determining such points by a mass of heterogeneous cases, collected 
together without a careful sifting of their histories, has over and over 
again been pointed out ; and it would be easy enough to meet them by 
an equal catalogue of cases in which the maternal mortality is almost 
nil. The results of the practice of many authorities are given in 
ChurchilFs work, where we find, for example, that out of forty-six 
cases of Merriman's, not one proved fatal. The same fortunate result 
happened in sixty-two cases of Ramsbotham's. His conclusion is 
that " there is undoubtedly some risk incurred by the mother, but not 
more than by accidental premature labor," and this conclusion, as 
regards the mother, is that which has long ago been arrived at by the 
majority of British obstetricians, who undoubtedly have more expe- 
rience of the operation than those of any other nation. With regard 
to the child, even if the German statistics be taken as reliable, they 
would hardly be accepted as contra-indicating the operation, inasmuch 
as it is intended to save the mother from the dangers of the more 
serious labor at term, and, in many cases, to give at least a chance to 
the child, whose life would otherwise be certainly sacrificed. The 
result, moreover, must depend to a great extent on the method of oper- 
ation adopted, for many of the plans of inducing labor recommended 



DEFORMITIES OF THE PELVIS. 419 

are certainly, in themselves, not devoid of danger both to the mother 
and the child. It may, I think, be admitted, as Duncan contends, 
that the operation has been more often performed than is absolutely 
necessary, and that the higher degrees of pelvic contraction are much 
more uncommon than has been supposed to be the case. That is a 
very valid reason for insisting on a careful and accurate diagnosis, but 
not for rejecting an operation which has so long been an established 
and favorite resource. 

AVhen the induction of labor has been determined on, the precise 
period at which it should be resorted to becomes a question for anxious 
consideration, since the longer it is delayed the greater, of course, are 
the dangers for the child. Many tables have been constructed to guide 
us on this point, which are not, on the whole, of so much service as 
they might appear to be, on account of the difficulty of determining 
with minute accuracy the amount of contraction. The following, 
however, which is drawn up by Kiwisch, may serve for a guide in 
settling this question : 

Inches. Lines. 
When the sacropubic diameter is 2 and 6 or 7 induce labor at 30th week. 
i. .. 2 .< s " 9 " " 3i s t 

2 " 10 " 11 " " 32d 
m «. 3 .< _ •< .< 33cl 

3 " I " " 33d " 
3 " 2 or 3 " " 34th 

., w 3 " 4 " 5 " " 35th " 

m « 3 " 5 " 6 " " 36th " 

In cases of moderate deformity, when labor pains have been induced, 
the further progress of the case may be left to Nature ; but in more 
marked cases, as in those below three inches, it will often be found 
necessary to assist delivery by turning or by the forceps, the former 
being here specially useful, on account of the extreme pliability of the 
head, and the facility with which it may be drawn through the con- 
tracted brim. By thus combining the two operations it may be quite 
possible to secure the birth of a living child even in pelves very con- 
siderably deformed. 

Production of Abortion in Extreme Deformity. — When the 
contraction is so great as to necessitate the induction of the labor before 
the sixth month, or, in other words, before the child has reached a 
viable age, it would be preferable to resort to a very early production 
of abortion. The operation is then indicated, not for the sake of the 
child, but to save the mother from the deadly risk to which she would 
otherwise be subjected. As in these cases the mother alone is con- 
cerned, the operation should be performed as soon as we have posi- 
tively determined the existence of pregnancy. No object can be gained 
by waiting until the development of the child is advanced to any 
extent, and the less the foetus is developed, the less will be the pain 
and the risk the mother has to undergo. There is no amount of de- 
formity, however great, in which we could not succeed in bringing on 
miscarriage by some of the numerous means at our disposal ; and, in 
spite of Dr. Radford's objections, who maintains that the obstetrician 
is not justified in sacrificing the life of a human being more tliau once, 
when the mother knows that she cannot give birth to a viable child, 
there are few practitioners who would not deem it their duty to spare 
the mother the terrible dangers of the Caesarean section. 



420 LABOK, 



CHAPTEE XIII. 

HEMORRHAGE BEFOEE DELIVERY: PLACENTA PREVIA. 

The hemorrhages which are the result of an abnormal situation of 
the placenta, partially or entirely over the internal os uteri, have 
formed a most fruitful theme for discussion. The explanation of the 
abnormal placental site, the sources of the blood and the causes of its 
escape, the means adopted by Nature for its arrest, and the proper 
treatment, have, each aud all of them, been the subject of endless con- 
troversies, which are not yet by any means settled. It must be ad- 
mitted, too, that the extreme importance of the subject amply justifies 
the attention which has been paid to it; for there is no obstetric 
complication more apt to produce sudden and alarming effects, and 
none requiring more prompt and scientific treatment. 

Definition. — By placenta prcevia we mean the insertion of the pla- 
centa at the lower segment of the uterine cavity, so that a portion of 
it is situated, wholly or partially, over the iuternal os uteri. In the 
former case there is complete or central placental presentation, in the 
latter an incomplete or marginal presentation. 

Causes. — The causes of this abnormal placental site are not fully 
understood. It was supposed by Tyler Smith to depend on the ovule 
Dot having been impregnated until it had reached the lower part of the 
uterine cavity. Cazeaux suggests that the uterine mucous membrane 
is less swollen and turgid than when impregnation occurs at the more 
ordinary place, and that, therefore, it offers less obstruction to the 
descent of the ovule to the lower part of the uterine cavity. An 
abnormal size, or unusual shape, of the uterine cavity may also favor 
the descent of the impregnated ovule ; the former probably explains 
the fact that placenta prasvia more generally occurs in women who 
have already borne children. Muller believes that it results from 
uterine contractions occurring shortly after conception, which force the 
ovum down to the lower part of the uterine cavity. These are merely 
interesting speculations having no practical value, the fact being un- 
doubted that, in a not inconsiderable number of cases — estimated by 
Johnson and Sinclair as 1 out of 573 — the placenta is grafted partially 
or entirely over the uterine orifice, although it is now generally 
admitted that the placenta is never attached to any portion of the 
cervix itself. 

History. — Placenta prsevia was not unknown to the older writers, 
who believed that the placenta had originally been situated at the 
fundus, from which it had accidentally fallen to the lower part of the 
uterus. Portal, Levret, Poederer, and especially the British author 
Rigby, were among those whose observations tended to improve the 



HEMORRHAGE BEFORE DELIVERY. 421 

state of obstetrical knowledge as to its real nature. To Rigby we owe 
the term unavoidable hemorrhage, as a synonym for placenta previa, 
and as distinguishing hemorrhage from this source from that resulting 
from separation of the placenta at its more usual position, termed by 
him, in coutra-distinction, accidental hemorrhage. These names, adopted 
by most writers on the subject, are obviously misleading, as they assume 
an essential distinction in the etiology of the hemorrhage in the two 
classes of cases, which is not always warranted. 

It is of the utmost importance to a right understanding of the nature 
and treatment of placenta prsevia that we should fully understand the 
source of the hemorrhage and the manner of its production ; but we 
shall be able to discuss this subject better after a description of the 
symptoms. 

Symptoms. — Although the placenta must occupy its unusual site 
from the earliest period of its formation, it rarely gives rise to appre- 
ciable symptoms before the last three months of utero-gestation. It is 
far from unlikely, however, that such an abnormal situation of the 
placenta may produce abortion in the earlier months, the site of its 
attachment passing unobserved. 

The earliest symptom which causes suspicion is the sudden occur- 
rence of hemorrhage, without any appreciable cause. The amount of 
blood lost varies considerably. In some cases the first hemorrhage is 
comparatively slight, and is soon spontaneously arrested ; but, if the 
case be left to itself, the flow after a lapse of time — it may be a few 
days, or it may be weeks — again commences in the same unexpected 
way, and each successive hemorrhage is more profuse. The losses 
show themselves at different periods. They rarely begin before the 
end of the sixth month, more often nearer the full period, and some- 
times not until labor has actually commenced. The hemorrhage is 
said, but this is doubtful, to often coincide with what would have been 
a menstrual period ; possibly on account of the physiological conges- 
tion of the uterine organs then present. Should the first loss not show 
itself until at or near the full time, it may be tremendous, and a few 
moments may suffice to place the patient's life in jeopardy. Indeed, it 
may be safely accepted as an axiom, that once hemorrhage has occurred, 
the patient is never safe ; for excessive losses may occur at any moment 
without warning, and when assistance is not at hand. It often happens 
that premature labor comes on after one or more hemorrhages. 

In any case of placenta prsevia, when labor has commenced, whether 
premature or at the full time, the hemorrhage may become excessive, 
and with each pain fresh portions of placenta may be detached and 
fresh vessels torn and left open. Under these circumstances the blood 
often escapes in greater quantity with each successive pain, and 
diminishes in the interval. This has long been looked upon as a 
diagnostic mark by which avc can distinguish between the so-called 
" unavoidable " and " accidental " hemorrhage ; in the latter the flow 
being arrested during the pains. The distinction, however, is altogether 
fallacious. The tendency of uterine contraction in placenta pracvia, as 
in all other forms of uterine hemorrhage, is to constrict the vessels 
from which the blood escape.-, and so to lessen the flow. The appar- 



422 LABOR. 

ently increased flow during the pains depends on the pains forcing out 
blood which has already escaped from the vessels. In one way, up to 
a certain point, the pains do favor hemorrhage, by detaching fresh por- 
tions of placenta ; but the actual loss takes place chiefly during the 
intervals, and not during the continuance of contraction. 

On vaginal examination, if the os be sufficiently open to admit the 
finger, which it generally is on account of the relaxation produced by 
the loss of blood, we shall almost always be able to feel some portion 
of presenting placenta. If it be a central implantation, we shall find 
the aperture of the cervix entirely covered by a thick, boggy mass 
which is to be distinguished from a coagulum by its consistence, and 
by its not breaking down under the pressure of the finger. Through 
the placental mass we may feel the presenting part of the foetus ; but 
not as distinctly as when there is no intervening substance. In partial 
placental presentations the bag of membranes, and above it the head 
or other presentation, will be found to occupy a part of the circle of 
the os, the rest being covered by the edge of the placenta. In marginal 
presentations we may only be able to make out the thickened edge of 
the afterbirth, projecting at the rim of the os. If the cervix be high, 
and the gestation not advanced to term, these points may not be easy 
to make out, on account of the difficulty of reaching the cervix ; and, 
as accurate diagnosis is of the utmost importance, it is proper to intro- 
duce two fingers, or even the whole hand, so as thoroughly to explore 
the condition of the parts. The lower portion of the uterine ovoid 
may be observed to be more than usually thick and fleshy; and 
Gendrin has pointed out that ballottement cannot be made out. The 
accuracy of our diagnosis may be confirmed, in doubtful cases, by 
finding that the placental bruit is heard over the lower part of the 
uterine tumor. 

Dr. Wallace 1 has suggested that vaginal auscultation may be service- 
able in diagnosis, and states that, by means of a curved wooden stetho- 
scope, the placental bruit may be heard with startling distinctness. 
This is, however, a manoeuvre that can hardly be generallv carried out 
in actual practice. 

It is now generally admitted by authorities that the immediate 
source of the hemorrhage is the lacerated utero-placental vessels. Only 
a few years ago Sir James Y. Simpson advocated, with his usual energy, 
the theory, sustained by his predecessor, Dr. Hamilton, that the chief, 
if not the only, source of hemorrhage was the detached portion of the 
placenta itself. He argued that the blood flowed from the portion of 
the placenta which was still adherent into that which was separated, 
and escaped from the surface of the latter ; and on this supposition he 
based his practice of entirely separating the j^lacenta, having observed 
that, in many cases in which the afterbirth had been expelled before 
the child, the hemorrhage had ceased. The fact of the cessation of the 
hemorrhage, when this occurs, is not doubted ; but Simpson's explana- 
tion is contested by most modern writers. The site of the loss was actu- 
ally demonstrated by the late Dr. Mackenzie in a series of experiments, in 

i Edin. Med. Jcmrn., vol. 1872-73, p. 427. 



HEMORRHAGE BEFORE DELIVERY. 423 

which he partially detached the placenta in pregnant bitches, and found 
that the blood flowed from the walls of the uterus, and not from the 
detached surface of the placenta. The arrangement of the large venous 
sinuses, opening as they do on the uterine mucous membrane, favors 
the escape of blood when they are torn across; and it is from them, 
possibly to some extent also from the uterine arteries, that the blood 
comes, just as in post-partum hemorrhage, when the whole, instead of 
a part, of the placental site is bared. 

Various explanations have been given of the causes of the hemor- 
rhage. For long it was supposed to depend on the gradual expansion 
of the cervix during the latter months of pregnancy, which separated 
the abnormally placed placenta. It has been seen, however, that this 
shortening of the cervix is apparent only, and that the cervical canal 
is not taken up into the uterine cavity during gestation, or, at all 
events, only during the last week or so. This, therefore, cannot be 
admitted as an explanation of placental separation. Jaequemier pro- 
posed another theory, which has been adopted by Cazeaux. He 
maintains that during the first six months of utero-gestation the 
superior portion of the uterus is more especially developed, as shown 
by the pyriform shape of the fundus during the time ; and that, as the 
placenta is usually attached in that situation, and then attains its 
maximum of development, its relations to its attachments are undis- 
turbed. During the last three months of pregnancy, on the contrary, 
the lower segment of the uterus develops more than the upper, while 
the placenta remains nearly stationary in size ; the inevitable result 
being a loss of proportion between the cervix and the placenta, and 
the detachment of the latter. There are various objections which can 
be brought against this theory ; the most important being that there is 
no evidence at all to show that the lower segment of the uterus does 
expand more in proportion than the upper during the latter months of 
pregnancy. Barnes's theory is based on the supposition that the loss 
of relation between the uterus and placenta is caused by excess of 
growth on the part of the placenta itself over that of the cervix, which 
is not adapted for its attachment. The placenta, on this hypothesis, 
grows away from the site of its attachment, and hemorrhage results. 
It will be observed that neither this theory nor that propounded by 
Jaequemier is readily reconcilable with the fact that hemorrhage fre- 
quently does not begin until labor has commenced at term. Inasmuch 
as the loss of relation between the placenta and its attachments, which 
they both presuppose, must exist in every case of placenta praevia, 
hemorrhage should always occur during some part of the last three 
months of pregnancy. Matthews Duncan 1 has recently investigated 
the whole subject at length, and maintains that the hemorrhages are 
accidental, not unavoidable, being due to causes precisely similar to 
those which give rise to the occasional hemorrhages when the placenta 
is normally placed. The abnormal situation of the placenta of course 
reuders these causes more apt to operate; but in their action he believes 
them to be precisely similar to those of accidental hemorrhage, properly 

» Edin. Med. Journ., vol. 1373-74, pp. 335, 520; and Brit. Med. Journ., vol. ii. pp. 499, 537, 625. 



424 LABOR. 

so called. Separation of the placenta from expansion of the cervix he 
believes to be the cause of hemorrhage after labor has begun, and then 
it may strictly be called unavoidable ; but hemorrhage is comparatively 
seldom so produced during the continuance of pregnancy. " There 
are," says Duncan, " four ways in which this kind of hemorrhage may 
occur : 

"1, By the rupture of a utero-placental vessel at or about the in- 
ternal os uteri. 

" 2. By the rupture of a marginal utero-placental sinus within the 
area of spontaneous premature detachment, when the placenta is in- 
serted not centrally or covering the internal os, but with a margin at 
or near the internal os. 

" 3. By partial separation of the placenta from accidental causes, 
such as a jerk or fall. 

"4. By a partial separation of the placenta, the consequence of 
uterine pains producing a small amount of dilatation of the internal 
os. Such cases may be otherwise described as instances of miscarriage 
commencing, but arrested at a very early stage." 

I see no reason to doubt the possibility of hemorrhage being due, 
in many cases, to the first three causes, and in its production it would 
strictly resemble accidental hemorrhage. The fourth heading refers 
the hemorrhage to partial separation, in consequence of commencing 
dilatation of the cervix, but it explains the dilatation by the suppo- 
sition of commencing miscarriage. This latter hypothesis seems to be 
as needless as those which presuppose a want of relation between the 
placenta and its attachments. We know that, quite independently of 
commencing miscarriage, uterine contractions are constantly occurring 
during the continuance of pregnancy. There is no reason to suppose 
that these contractions do not affect the cervical as well as the fundal 
portions of the uterus ; and in cases in which the placenta is situated 
partially or entirely over the os, one or more stronger contractions 
than usual may, at any moment, produce laceration of the placental 
attachments in that neighborhood. 

Pathological Changes in the Placenta. — A careful examination 
of the placenta may show pathological changes at the site of separation, 
such as have been described by Gendrin, Simpson, and other writers. 
They probably consist of thromboses in the placental cotyledons, and 
effused blood-clots, variously altered and decolorized, according to the 
lapse of time since separation took place. Changes occur in the por- 
tion of the placenta overlying the os uteri, whether separation has 
occurred or not. There may be atrophy of the placental structure 
in this situation, as well as changes of form, such as complete or 
partial separation into two lobes, the junction of which overlies the 
os uteri. 1 

The history of delivery, if left (o Nature, is especially worthy of 
study, as guiding to proper rules of treatment. It sometimes happens, 
when the paius are very strong and the delivery rapid, that labor is 
completed without any hemorrhage of cousequence. "Although," 

1 Sinelius: Arch. gen. de Med., 1861, torn. ii. 



HEMORRHAGE BEFORE DELIVERY. 425 

says Cazeaux, "hemorrhage is usually considered to be inevitable 
under such circumstances, yet it may not appear even during the 
labor ; and the dilatation of the os uteri may be effected without the 
loss of a drop of blood." Again, Simpson conclusively showed that, 
when the placenta was expelled before the birth of the child, all 
hemorrhage ceased. 

Barnes's theory of placenta praevia, which has been pretty generally 
adopted, explains satisfactorily both these classes of cases. 

He describes the uterine cavity as divisible into three zones or 
regions. When the placenta is situated in the upper or middle of 
these zones, no separation or hemorrhage need occur during labor. 
When, however, it is situated partially or entirely in the lower or 
cervical zone, the expansion of the cervix during labor must produce 
more or less separation and consequent loss of blood. As soon as the 
previous portion of the placenta is sufficiently separated, provided 
contraction of the uterine tissue be present to seal up the mouths of 
the vessels, hemorrhage no longer takes place. The placenta may not 
be entirely detached, but no further hemorrhage occurs, in consequence 
of the remaining portion being engrafted on the uterus beyond the 
region of unsafe attachment. 

In the former, then, of these classes of cases, the absence of hemor- 
rhage is explained on this theory, by the pains being sufficiently rapid 
and strong to complete the separation of the placental attachment 
from the lower cervical zone before flooding had taken place ; in the 
latter it ceases, not necessarily because the entire placenta is expelled, 
but because of its detachment from the area of dangerous im- 
plantation. 

The amount of cervical expansion required for this purpose varies 
in different cases. Dr. Duncan 1 estimates the limit of the spontaneous 
detaching area to be a circle of four and a half inches diameter, and 
that, after the cervix has expanded to that extent, no further separa- 
tion or hemorrhage takes place. To admit of the passage of a full- 
sized head, Barnes estimates that expansion to about a circle of six 
inches diameter is necessary ; on the other hand, he has sometimes 
observed " that the hemorrhage has completely stopped when the os 
uteri opened to the size of the rim of a wineglass, or even less." 

It will be seen then that in this, as in every other form of puerperal 
hemorrhage, the tendency of uterine contraction is to check the hem- 
orrhage; and that, provided the pains are sufficiently energetic, Nature 
may be capable of stopping the flooding without artificial aid. It is 
but rarely, however, that she can be trusted for this purpose ; and we 
shall presently see that these theoretical views have an important 
practical bearing on the subject of treatment. 

Prognosis. — The prognosis to both the mother and child is certainly 
grave in all cases of placenta previa. Read, in his treatise on placenta 
praevia, estimates the maternal mortality, from the statistics of a large 
number of cases, as one in four and a half cases, and Churchill as one 
in three. This is unquestionably too high an estimate, and based on 

i Obstet. Trans , vol. xv. \> I 



426 LABOR. 

statistics the accuracy of which cannot be relied on. The mortality 
will, of course, greatly depend on the treatment adopted. Doubtless, 
if cases were left to Nature, the result would be quite as unfavorable 
as Read supposes. But if properly managed, much more successful 
results may safely be anticipated. Out of sixty-seven cases recorded 
by Barnes, the deaths were six, or one in eight and a half. Under 
any circumstances the risks to the mother are very great. Churchill 
estimates that more than half the children are lost. The reasons for 
the great danger to the child are very obvious, subjected as it is to the 
risk of asphyxia from the loss of the maternal blood, and from its 
respiration being carried on during labor by a placenta which is only 
partially attached ; many children also perish from prematurity, or 
from malpresentation. 

Treatment. — Whenever, in the latter months of pregnancy, a sudden 
hemorrhage occurs, the possibility of placenta prsevia will naturally 
suggest itself; and by a careful vaginal examination, which under 
such circumstances should always be insisted on, the existence of this 
complication will generally be readily ascertained. It is seldom that 
the os is not sufficiently dilated to enable us to satisfy ourselves whether 
the placenta is presenting. 

The first question that will arise is, Are we justified in temporizing, 
using means to check the hemorrhage, and allowing the pregnancy to 
continue ? This is the course which has generally been recommended 
in works on midwifery. We are told to place the patient on a hard 
mattress, not to heat or overburden her with clothes, to keep her abso- 
lutely at rest, to have the room cool and well aired, to apply cold 
cloths to the vulva and lower part of the abdomen, to administer cold 
and acidulated drinks in abundance, and to prescribe acetate of lead 
and opium, or gallic acid, on account of their supposed haemostatic 
effect. The judiciousness of these recommendations has been strongly 
contested. An interesting discussion took place at the Obstetrical 
Society of London, 1 on a paper in which Dr. Greenhalgh advised the 
immediate induction of labor in all cases of placenta prsevia. No fewer 
than six metropolitan teachers of midwifery took part in it, and, 
although they differed in detail, they all agreed as to the unadvisability 
of allowing pregnancy to progress when the existence of placenta prsevia 
had been distinctly ascertained. The reasons for this course are obvi- 
ous and unanswerable. The labor, indeed, very often comes on of its 
own accord ; but should it not do so the patient's life must be consid- 
ered to be always in jeopardy until the case is terminated, for no one 
can be sure that most dangerous, or even fatal, flooding may not at 
any moment come on ; aud the nearer to term the patient is, the greater 
the risk to which she is subjected. Nor is the safety of the child likely 
to be increased by delay. Provided it has arrived at a viable age, the 
chances of its being born alive may be said to be greater if pregnancy 
be terminated at once, than if repeated floodings occur. I think, 
therefore, that it may be safely laid down as an axiom, that no attempt 
should be made to prevent the termination of pregnancy, but that our 

1 Obstet. Trans., vol. vi. p. 188. 



HEMORRHAGE BEFORE DELIVERY. 427 

treatment should rather contemplate its conclusion as soou as possible. 
An exception may, however, be made to this rule when the hemorrhage 
occurs for the first time before the seventh month of utero-gestatiou. 
The chances of the child surviving would then be very small, and if 
the hemorrhage be not alarmiug, as at that early period is likely to be 
the case, the measures indicated above may be employed, in the hope 
of carrying on the pregnancy until there is a prospect of the patient 
being delivered of a living child. But little benefit is likely to accrue 
from astringent drugs. Perfect rest in bed is more likely to be bene- 
ficial than anything else. 

When the period of pregnancy, or the urgency of the case, deter- 
mines us to forego any attempt at temporizing, there are various plans 
of treatment to be considered. These are chiefly: 1. Puncture of the 
membranes. 2. Plugging the vagina. 3. Turning. 4. Partial or 
complete separation of the jitocenta. It will be well to consider in 
detail the relative advantages of, and indications for, each of these. 
It is seldom, however, that we can trust to any one per se ; in most 
cases, two or more are required to be used in combination. 

1. Puncture of the membranes is recommended by Barnes as the 
first measure to be adopted in all cases of placenta prsevia sufficient 
to cause anxiety. "It is," he says, "the most generally efficacious 
remedy, and it can always be applied." The primary object gained is 
the increase of uterine contraction by the evacuation of the liquor 
amnii. Although the first effect of this may be to increase the flow 
of blood by further separation of the placenta, the flooding can gen- 
erally be commanded by plugging until the os is sufficiently dilated 
to permit the passage of the child. As a rule, there is no great diffi- 
culty in effecting the puncture, especially if the placental presentation 
be only partial. A uterine sound, or other suitable contrivance, 
guided by the examining finger, is passed through the cervix and 
pushed through the membranes. In complete placenta prsevia it may 
not be so easy to effect the evacuation of the liquor amnii ; and, 
although many authorities advise the penetration of the substance of 
the placenta itself, I am inclined to think that it would be better to 
abandon the attempt, in such cases, aud trust to other methods of treat- 
ment. 

The objections which have been raised to puncture of the mem- 
branes are chiefly that it interferes with the gradual dilatation of the 
os, and renders the operation of turning much more difficult. The os 
is not, however, so regularly dilated by the bag of membranes in cases 
of placenta pnevia as it is in ordinary labors. Moreover, as the cer- 
vical tissues are generally relaxed by the hemorrhage, the dilatation is 
easily effected. Should we desire to dilate the os preparatory to turn- 
ing, we can readily do so by means of fluid dilators. The new dilator 
of Champetier de Ribes will probably be found very useful, since it 
will not only rapidly and effectively dilate the cervix and thus pre- 
pare the way for subsequent turning, but also act as an efficient plug. 
The objections, therefore, are not so weighty as they might have heen 
before these artificial dilators were used. I am inclined, for these 



428 LABOR. 

reasons, to agree with the recommendation that puncture of the mem- 
branes should be resorted to in all cases of placenta prsevia. 

2. Plugging of the vagina, or, still better, of the cavity of the 
cervix itself, is especially serviceable in cases in which the os is not 
sufficiently dilated to admit of turning, or of separation of the placenta, 
and in which the hemorrhage still continues after the evacuation of 
the liquor amnii. By means of this contrivance the escape of blood 
is effectually controlled. 

A good way of plugging is to introduce a sponge tent of sufficient 
size into the cervical canal, and to keep it in situ by a vaginal plug ; 
the best material for the latter, and the method of introduction, are 
described under the head of Abortion (p. 264). The sponge tent not 
only controls the hemorrhage more effectually than any other means, 
but is, at the same time, effecting dilatation of the cervix. It cannot 
be left in many hours, on account of the irritation produced and of the 
fetor from accumulating vaginal discharges, and the consequent risk 
of septic absorption. This is by no means slight, and it is now pretty 
generally recognized that the plug should not be used unless other 
means of treatment are inapplicable on account of the want of dilata- 
tion of the os. As long as it is in position, we should carefully 
examine, from time to time, to see that no blood is oozing past it. If 
preferred, a Barnes bag may be used for the same purpose. 

While the plug is in situ other modes of exciting uterine action may 
be very advantageously employed, such as a firm abdominal bandage, 
occasional friction over the uterus, and repeated doses of ergot. The 
last is specially recommended by Dr. Greenhalgh, who used, at the 
same time, a plug formed of an oblong India-rubber baM inflated with 
air and covered with spongio-piline. 

On the removal of the plug we may find that considerable dilatation 
has taken place, perhaps to a sufficient extent to admit of labor being 
safely concluded by the natural efforts. In that case we shall find 
that, although the pains continue, no fresh hemorrhage occurs. Should 
it do so, it will be necessary to adopt further measures. 

3. Turning has long been considered the remedy par excellence in 
placenta prsevia ; and it is of unquestionable value in suitable cases. 
Much harm, however, has been done when it has been practised before 
the os was sufficiently dilated to admit of the passage of the hand, or 
when the patient was so exhausted by previous hemorrhage as to be 
unable to bear the shock of the operation. The records of many fatal 
cases in the practice of those who taught, as did the large majority of 
the older writers, that turning at all risks was essential, conclusively 
prove this assertion. 

It is most likely to prove serviceable when, either at first or after 
the use of the tampon, the os is sufficiently dilated to admit the hand, 
and when the strength of the patient is not much enfeebled. If she 
have a small, feeble, and thready pulse, it is certainly inapplicable, 
unless all other methods of arresting the hemorrhage have failed. 
And, even then, it would be well to attempt to rally the patient from 
her exhausted state by stimulants, etc., before the operation is com- 
menced. 



HEMORRHAGE BEFORE DELIVERY. 429 

Provided the placental presentation be partial, the operation can be 
performed without difficulty in the usual way. In central implanta- 
tion the passage of the hand may give rise to some difficulty. Dr. 
Rigby recommends that it should be pushed through the substance of 
the placenta until it reaches the uterine cavity. It is hardly possible 
to conceive how this could be done without completely detaching the 
placenta, and still less to understand how the foetus could be dragged 
through the aperture thus made. It will be far better to pass the 
hand by the border of the placenta, separating it as Ave do so ; and, if 
we can ascertain to which side of the cervix it is least attached, that 
should be chosen for the purpose. In all cases in which it is possible, 
turning by the bi-polar method should be preferred. In cases of 
placenta prsevia especially it offers many advantages. The operation 
can be soon performed ; complete dilatation of the os is not so neces- 
sary ; and it involves less bruising of the cervix, which is likely to be 
specially dangerous. When once a lower extremity has been brought 
within the os, the delivery should not be hurried. The limb of the 
child forms a plug, which effectually prevents all further loss ; and 
we may then safely wait until we can excite uterine contraction aud 
terminate the labor with safety. The results of this method of treating 
placenta prsevia have been excellent. Hoffmeier relates thirty-seven 
cases managed in this way with only one death, and Behm thirty-five 
with none. 1 Fortunately, the relaxation of the uterus, which is so 
often present, facilitates this manner of performing version, and it can 
generally be successfully accomplished. Should the case be one which 
is otherwise suitable for turning, and the requisite amount of dilata- 
tion of the cervix not be present, the latter can generally be effected 
in the space of an hour or more (while at the same time a further loss 
of blood is effectually prevented) by the use of fluid dilators. 

4. Entire separation of the placenta was originally recommended 
by Simpson in his well-known paper on the subject. The reasons 
which induced him to recommend it have already been stated. It is a 
mistake to suppose, however, as is so often done, that he intended to 
recommend it in all cases alike. This supposition he was always 
careful to deny. He advised it especially — 

1. When the child is dead. 

2. When the child is not yet viable. 

3. When the hemorrhage is great and the os uteri is not yet suffi- 
ciently dilated for safe turning. This was the state in eleven out of 
thirty-nine cases (Lee). 

4. When the pelvic passages are too small for safe and easy turning. 

5. When the mother is too exhausted to bear turning. 

6. When the evacuation of the liquor amnii fails. 

7. When the uterus is too firmly contracted for turning. 2 

These are very much the cases in which all modern accoucheurs 
would exclude the operation of turning: and it was specially when 
that was unsuitable that Simpson advised extraction of the placenta. 

1 Zeitschr. f. Geburt. und Gyriak., Bd. viii. S. S3 : Bd. ix. S. 373, " Die combinirte Wendung bei 
Phieenta Prsevia." 
« Selected Obst. Works, p. 68. 



430 LABOR. 

As his theory of the source of hemorrhage is now almost universally 
disbelieved, so has the practice based on it fallen into disuse, and it 
need not be discussed at length. It is very doubtful whether the 
complete separation and extraction of the placenta was a feasible oper- 
ation ; unquestionably it can be by no means so easy as Simpson's 
writings would lead us to suppose. The introduction of the hand far 
enough to remove the placenta in an exhausted patient would probably 
cause as much shock as the operation of turning itself; and another 
very formidable objection to the procedure is the almost certain death 
of the child, if any time elapse between the separation of the placenta 
and the completion of delivery. The modification of this method, so 
strongly advocated by Barnes, is certainly much easier of application, 
and Avould appear to answer every purpose that Simpson's operation 
effected. It is impossible to describe it better than in Barnes's own 
words i 1 

" The operation is this: Pass one or two fingers as far as they will 
go through the os uteri, the hand being passed into the vagina if 
necessary ; feeling the placenta, insinuate the finger between it and the 
uterine wall ; sweep the finger round in a circle so as to separate the 
placenta as far as the finger can reach ; if you feel the edge of the 
placenta, where the membranes begin, tear open the membranes care- 
fully, especially if these have not been previously ruptured ; ascertain, 
if you can, what is the presentation of the child before withdrawing 
your hand. Commonly, some amount of retraction of the cervix takes 
place after the operation, and often the hemorrhage ceases." 

It will be seen from what has been said, that no one rule of practice 
can be definitely laid down for all cases of placenta prsevia. Our 
treatment in each individual case must be guided by the particular 
conditions that are present ; and, if only we bear in mind the natural 
history of the hemorrhage, we may confidently expect a favorable 
termination. 

It may be useful, in conclusion, to recapitulate the rules which have 
been laid down for treatment in the form of a series of propositions : 

1. Before the child has reached a viable age, temporize, provided 
the hemorrhage be not excessive, until pregnancy has advanced suffi- 
ciently to afford a reasonable hope of saving the child. For this 
purpose the chief indication is absolute rest in bed, to which other 
accessory means of preventing hemorrhage, such as cold, etc., may be 
added. 

2. In hemorrhage occurring after the seventh month of utero-gesta- 
tion, no attempt should be made to prolong the pregnancy. 

3. In all cases in which it can be easily effected, the membranes 
should be ruptured. By this means uterine contractions are favored 
and the bleeding vessels compressed. 

4. If the hemorrhage be stopped, the case may be left to Nature. 
If flooding continue, and the os be not sufficiently dilated to admit of 
the labor being readily terminated by turning, the os and the vagina 
should be carefully plugged, while uterine contractions are promoted 

1 Obstet. Operations, 2d ed.. p. 417. 



PLATE V. 






-Placental site 



■ ii 



Blood clot 



Placental site 



Posterior wall of uterus 



Retro-pla cental 
blood clot 




Placenta attached to 

wall producing 

its inversion 



\ Anterior wall 
of uterus 



Membranes 



Placenta 



Vertical Mesial Section of Uterus with Placenta partially attached. 

From a case of abdominal section for haemorrhage 

during labor. (After Barbour.) 



HEMORRHAGE BEFORE DELIVERY. 4bl 

by abdominal bandages, uterine compression, and ergot. The ping 
must not be left in beyond a few hours, and careful antisepsis should 
be used. 

5. If, on removal of the ping, the os be sufficiently expanded, and 
the general condition of the patient be good, the labor may be ter- 
minated by turning, the bi-polar method being used if possible, and 
the lower extremity of the child will form a plug until delivery is 
completed. If the os be not open enough, it may be advantageously 
dilated by a fluid dilator bag, which also acts as a plug. 

6. Instead of, or before resorting to, turning, the placenta may be 
separated around the site of its attachment to the cervix. This prac- 
tice is specially to be preferred when the patient is much exhausted 
and in a condition unfavorable for bearing the shock of turning. 



CHAPTER XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED 

PLACENTA. 

Definition. — This is the form of hemorrhage which is generally 
described in obstetric works as accidental, in contradistinction to the 
unavoidable hemorrhage of placenta previa. In discussing the latter 
we have seen that the term " accidental" is one that is apt to mislead, 
and that the causation of the hemorrhage in placenta prsevia is, in 
some cases at least, closely allied to that of the variety of hemorrhage 
we are now considering. 

When, from any cause, separation of a normally situated placenta 
occurs before delivery, more or less blood is necessarily effused from 
the ruptured utero-placental vessels, and the subsequent course of the 
case may be twofold : 1. The blood, or at least some part of it, may 
find its way between the membranes and the decidua, and escape from 
the os uteri. This constitutes the typical "accidental" hemorrhage of 
authors. 2. The blood may fail to find a passage externally, and may 
collect internally (see Plate V.), giving rise to very serious symptoms, 
and even proving fatal, before the true nature of the case is recognized. 
Cases of this kind are by no means so rare as the small amount of 
attention paid to them by authors might lead us to suppose; and, from 
the obscurity of the symptoms and difficulty of diagnosis, they merit 
special study. Dr. Goodell 1 has collected no less than 106 instances 
in which this complication occurred. 

Causes and Pathology. — The causes of placental separation may 
be very various. In a large number of cases it has followed an acci- 
dent or exertion (such as slipping down stairs, stretching, lifting heavy 

1 Amer. Journ. of Obstet., vol. ii. p 281. 



432 LABOR. 

weights, and the like) which has probably had the effect of lacerating 
some of the placental attachments. At other times it has occurred 
without such appreciable cause, and then it has been referred to some 
change in the uterus, such as a more than usually strong contraction 
producing separation, or some accidental determination of blood causing 
a slight extravasation between the placenta and the uterine wall, the 
irritation of which leads to contraction and further detachment. Causes 
such as these, which are of frequent occurrence, will not produce de- 
tachment except in women otherwise predisposed to it. It generally 
is met with in women who have borne many children, more especially 
in those of weakly constitution and impaired health, and rarely in 
priniiparae. Certain constitutional states probably predispose to it, 
such as albuminuria or exaggerated anemia ; and, still more so, de- 
generations and diseases of the placenta itself, or a diseased condition 
of the decidua due to endometritis. 

This form of hemorrhage rarely occurs to an alarming extent until 
the later months of pregnancy, often not until labor has commenced. 
The great size of the placental vessels in advanced pregnancy affords 
a reasonable explanation of this fact. 

Symptoms and Diagnosis. — If, after separation of a portion of 
the placenta, the blood finds its way between the membranes and the 
decidua, its escape per vaginam, even although in small amount, at 
once attracts attention, and reveals the nature of the accident. It is 
otherwise when we have to deal with a case of concealed hemorrhage, 
the diagnosis of which is often a matter of difficulty. Then the blood 
probably at first collects between the uterus and placenta. Sometimes 
marginal separation does not occur, and large blood-clots are formed 
in this situation, and retained there. More often the margin of the 
placenta separates, and the blood collects between the membranes and 
the uterine w^all, either toward the cervix, where the presenting part 
of the child may prevent its escape, or near the fundus. In the latter 
case especially, the coagula are apt to cause very painful stretching 
and distention of the uterus. The blood may also find its way into 
the amniotic cavity, but more frequently it does not do so ; probably, 
as Goodell has pointed out, because, " should the os uteri be closed, 
the membranes, however delicate, cannot, other things being equal, 
rupture any sooner from the uterine w^alls, for the sum of the resist- 
ance of the enclosed liquor amnii being equally distributed exactly 
counter-balances the sum of the pressure exerted by the effusion. " 
This point is of some practical importance, because, after rupture of 
the membranes, the liquor amnii is frequently found untinged with 
blood, and this might lead us to suppose ourselves mistaken in our 
diagnosis, if this fact were not borne in mind. 

The most prominent symptoms in concealed internal hemorrhage 
are extreme collapse and exhaustion, for which no adequate cause can 
be assigned. These differ from those of ordinary syncope, with which 
they might be confounded, chiefly in their persistence and severity, 
and in the presence of the symptoms attending severe loss of blood, 
such as coldness and pallor of the surface, great restlessness and 
anxiety, rapid and sighing respiration, yawning, feeble, quick, and 



HEMORRHAGE BEFORE LABOR. 433 

compressible pulse. AVheu there is severe internal, with slight exter- 
nal, hemorrhage, Ave may be led to a proper diagnosis by observing 
that the constitutional symptoms are much more severe than the 
amount of external hemorrhage Mould account for. Uterine pain is 
generallv present, of a tearing and stretching character, sometimes 
moderate in amount, more often severe, and occasionally amounting to 
intolerable anguish. It is often localized, and, doubtless, depends on 
the distention of the uterus by the retained coagula. If the disten- 
tion be marked, there may be an irregularity in the form of the uterus 
at the site of sanguineous effusion ; but this will be difficult to make 
out, except in women with thin and unusually lax abdominal parietes. 
A rapid increase in the size of the uterus has been described as a sign 
by Cazeaux and others. It is not very likely that this will be appre- 
ciable toward the end of utero-gestation, as a very large amount of 
effusion would be necessary to produce it. At an earlier period of 
pregnancy, at or about the fifth month, I made it out very distinctly 
in a case in my own practice. It obviously must have occurred to an 
enormous extent in a case related by Chevalier, in which post-mortem 
Cesarean section was performed under the impression that the preg- 
nancy had advanced to term, but only a three months' foetus was found, 
imbedded in coagula which distended the uterus to the size of a nine 
months' gestation. 1 Labor pains may be entirely absent. If present, 
thev are generally feeble, irregular, and inefficient. 

Differential Diagnosis. — The only condition, beside ordinary syn- 
cope, likely to be confounded with this form of hemorrhage, is rupture 
of the uterus, to which the intense pain and profound collapse induce 
considerable resemblance. The latter rarely occurs until after labor 
has been some time in progress, and after the escape of the liquor 
amnii ; whereas hemorrhage usually occurs either before labor has 
commenced, or at an early stage. The recession of the presentation, 
and the escape of the foetus into the abdominal cavity, in cases of rup- 
ture, will further aid in establishing the diagnosis. 

Prognosis. — The prognosis, when blood escapes externally, is, on 
the whole, not unfavorable. The nature of the case is apparent, and 
remedial measures are generally adopted sufficiently early to prevent 
serious mischief. It is different with the concealed form, in which 
the mortality is very great. Out of Goodell's 106 eases, no less than 
fifty-four mothers died. This excessive death-rate is, no doubt, partly 
due to the fact that extreme prostration often occurs before the exist- 
ence of hemorrhage is suspected, and partly to the accident generally 
happening in women of weakly and diseased constitution. The prog- 
nosis to the child is still more grave. Out of 107 children, only six 
were born alive. The almost certain death of the child may be ex- 
plained by the fact that, when blood collects between the uterus and 
the placenta, the foetal portion of the latter is probably lacerated, and 
the child then also dies from hemorrhage. 

Treatment. — In this, as in all other forms of puerperal hemor- 
rhage, the great hemostatic is uterine contraction, and that we must 

1 Journ. de Med. Clin, ct Pharm., torn. xxi. p. 363. 
28 



■m 



LABOR. 



try to encourage by all possible means. The first thing to be clone, 
whether the hemorrhage be apparent or concealed, is to rupture the 
membranes. If the loss of blood be only slight, this may suffice to 
control it, and the case may then be left to Nature. A firm abdominal 
binder should, however, be applied to prevent any risk of blood col- 
lecting internally, as there is nothing to prevent its filling the uterine 
cavity after the membranes are ruptured. Contraction may be further 
advantageously solicited by uterine compression, and by the adminis- 
tration of full doses of ergot. If hemorrhage continue, or if we have 
any reason to suspect concealed hemorrhage, the sooner the uterus is 
emptied the better. If the os be sufficiently dilated, the be^st practice 
will be to turn without further delay, using the bi-polar method if 
possible. If the os be not open enough, a Barnes bag should be in- 
troduced, while firm pressure is kept up to prevent uterine accumula- 
tion. Should the collapsed condition of the patient be very marked, 
the mere shock of the operation might turn the scale against her. 
Under such circumstances it may be better practice to delay further 
procedure until, by the administration of stimulants, warmth, the rectal 
or subcutaneous injection of saline solution, etc., we have succeeded ,i n 
producing some amount of reaction, keeping up, in the meanwhile, 
firm pressure on the uterus. Should the head be low down in the 
pelvis, it may be easier to complete labor by means of the forceps. 



CHAPTEE XV. 

HEMORRHAGE AFTER, DELIVERY. 

Its Importance. — Hemorrhage during, or shortly after, the third 
stage of labor is one of the most trying and dangerous accidents con- 
nected with parturition. Its sudden and unexpected occurrence just 
after the labor appears to be happily terminated, and its alarming 
effect on the patient, who is often placed in the utmost danger in a few 
moments, tax the presence of mind and the resources of the practi- 
tioner to the utmost, and render it an imperative duty on everyone 
who practises midwifery to make himself thoroughly acquainted with 
its causes, and preventive and curative treatment. There is no emer- 
gency in obstetrics which leaves less time for reflection and consulta- 
tion, and the life of the patient will often depend on the prompt and 
immediate action of the medical attendant. 

Frequency of Post-partum Hemorrhage. — Post-partum hemor- 
rhage is one of the most frequent complications of delivery. I do not 
know of any statistics which enable us to judge with accuracy of its 
frequency, but I believe it to be an unquestionable fact that, especially 
in the upper ranks of society, it is very common indeed. This is- 



HEMORRHAGE AFTER DELIVERY. 435 

probably due to the effects of civilization, and to the mode of life of 
patients of that class, whose whole surroundings tend to produce a 
lax habit of body which favors uterine inertia, the principal cause of 
post-partum hemorrhage. In the report of the Registrar-General for 
the live years from 1872 to 1876, 3524 deaths are attributed to flood- 
ing. The majority of these must have been caused by post-partum 

hemorrhage, although some mav have been from other forms. 

* 
Fortunately, it is, to a great extent, a preventable accident. I 

believe this fact cannot be too strongly impressed on the practitioner. 
If the third stage of labor be properly conducted, if every case be 
treated, as every case ought to be, as if hemorrhage were impending, 
it would be much more infrequent than it is. It is a curious fact 
that post-partum hemorrhage is much more common in the practice of 
some medical men than in that of others ; the reason being that those 
who meet with it oi'ten, are careless in their management of their 
patients immediately after the birth of the child. That is just the 
time when the assistance of a properly qualified practitioner is of 
value, much more so than before the second stage of labor is con- 
cluded; hence, when I hear that a medical man is constantly meeting 
with severe post-partum hemorrhage, I hold myself justified, ipso 
facto, in inferring that he does not know, or does not practice, the 
proper mode of managing the third stage of labor. 

Causes. — The placenta, as Ave have seen, is separated by the last 
pains, and the blood, which in greater or less quantity accompanies 
the foetus, probably comes. from the utero-placental vessels which are 
then lacerated. Almost immediately afterward the uterus contracts 
firmly, and, in a typical labor, assumes the hard cricket-ball form 
which is so comforting to the accoucheur to feel. (See Plate VI.) 
The result is the compression of all of the vascular trunks which 
ramify in its walls, both arteries and veins, and thus the flow of blood 
through them is prevented. By referring to what has been said as to 
the anatomy of the muscular fibres of the gravid uterus, especially at 
the placental site (p. 62), it will be seen how admirably they are 
adapted for this purpose. The arrangement of the vessels themselves 
favors the haemostatic action of uterine contraction. The large venous 
sinuses are placed in layers one above the other, in the thickness of 
the uterine walls, and they anastomose freely. When the superim- 
posed layers communicate with those immediately below them, the 
junction is by a falciform or semilunar opening in the floor of the 
vessel nearest the external surface of the uterus. Within the margins 
of this aperture there are muscular fibres, the contraction of which 
probably tends to prevent retrogression of blood from one layer of 
vessels into the other. The venous sinuses themselves are of* a flattened 
form, aud they are intimately attached to the muscular tissues. It is 
obvious, then, that these anatomical arrangements are eminently 
adapted to facilitate the closure of the vessels. They are, however, 
large, and are destitute of valves; and if contraction be absent, or if 
it be partial and irregular, it is equally easy to understand why blood 
should pour forth in the appalling amount which is sometimes 
observed. 



436 LABOR. 

If uterine action be firm, regular, and continuous, the vessels must 
be sealed up and hemorrhage effectually prevented. This fact has 
been doubted by many authorities. Gooch was the first to describe 
what he called a a peculiar form of hemorrhage" accompanying a 
contracted womb. Similar observations have been made by other 
writers, such as Yelpeau, Rigby, and Gendrin. Simpson says, on this 
point, that strong uterine contractions "are not probably so essential 
a part in the mechanism of the prevention of hemorrhage from the 
open orifices of the uterine veins as we might a priori -suppose." 1 
With regard to Gooch's cases, it has been pointed out that his own 
description proves that, however firmly the uterus may have contracted 
immediately after the expulsion of the child, it must have subse- 
quently relaxed, for he passed his hand into it to remove retained 
clots, a manoeuvre which he could not have practised had tonic con- 
traction been present. In some of these cases the hemorrhage has 
been found to come from a laceration of the cervix. Of course, blood 
may readily escape from a mechanical injury of this kind, although 
the uterus itself be in a satisfactory state of contraction ; and the pos- 
sibility of this occurrence should always be borne in mind. Instances 
of the successful treatment of this variety of post-partum hemorrhage 
by sutures applied to the lacerated cervix have been related by Pallen 
and others. 

Although, then, we may admit that post-partum hemorrhage is in- 
compatible with persistent contraction of the uterus, it by no means 
follows that the converse is true. On the- contrary, it is not uncom- 
mon to meet with cases in which the uterus is large, and apparently 
quite flaccid, and in which there is no loss of blood. Alternate relaxa- 
tion and contraction of the uterus after delivery are also of constant 
occurrence, and yet hemorrhage, during the relaxation, does not take 
place. The explanation no doubt is, that immediately after the birth 
of the child there was sufficient contraction to prevent hemorrhage, 
and that, during its continuance, coagula formed in the mouths of the 
uterine sinuses, by which they were sufficiently occluded to prevent 
any loss when subsequent relaxation occurred. 

In all probability both uterine contraction and thrombosis are in 
operation in ordinary cases ; and we shall presently see that all the 
means employed in the treatment of post-partum hemorrhage act by 
producing one or other of them. 

Uterine inertia after labor, then, may be regarded as the one great 
primary cause of post-partum hemorrhage ; but there are various sec- 
ondary causes which tend to produce it, one of the most frequent of 
which is exhaustion following a protracted labor. The uterus gets 
worn out by its efforts, and when the foetus is expelled, it remains in 
a relaxed state, and hemorrhage results. Over-distention of the uterus 
acts in the same way. Hence hemorrhage is very frequently met with 
when there has been an excessive amount of liquor amnii, or in mul- 
tiple pregnancies. One of the worst cases I ever met with was after 
the birth of triplets, the uterus having been of an enormous size. 

1 Selected Obstetric Works, p. 234. 



HEMORRHAGE AFTER DELIVERY. 437 

Rapid emptying of the uterus, during which there has not been suffi- 
cient time for complete separation of the placenta, often tends to the 
same result. This is the reason why hemorrhage so frequently follows 
forceps delivery, especially if the operation have been unduly hur- 
ried ; and it is one of the chief dangers in what are termed "precipi- 
tate labors." The general condition of the patient may also strongly 
predispose to it. Thus it is more often met with in women who have 
borne families, especially if they be weakly in constitution, compara- 
tively seldom in primiparse ; and for the same reason that after-pains 
are most common in the former, namely, that the uterus, weakened by 
frequent childbearing, contracts inefficiently. The experience of prac- 
titioners in the tropics shows that European women, debilitated by 
the relaxing effects of warm climates, are peculiarly prone to it, and 
it forms one of the chief dangers of childbirth amongst the English 
ladies in India. 

Another important cause of post-partum hemorrhage is partial and 
irregular contraction of the uterus. Part of the muscular tissue is 
firmly contracted, while another part is relaxed, and the latter very 
often the placental site. This has been especially dwelt on by Simp- 
son. He says: "The morbid condition which is most frequently and 
earliest seen in connection with post-partum hemorrhage, is a state of 
irregularity and want of equability in the contractile action of different 
parts of the uterus — and, it may be, in different planes of the mus- 
cular fibres — as marked by one or more points in the organ feeling 
hard and contracted, at the same time that other portions of the 
parietes are soft and relaxed." 

One peculiar variety, which has been much dwelt on by writers, 
and is a prominent bugbear to obstetricians, is the so-called hour-glass 
contraction. This in reality seems to depend on spasmodic contraction 
of the internal os uteri, by means of which the placenta becomes 
encysted in the upper portion of the uterus, which is relaxed. On 
introducing the hand, it first passes through the lax cervical canal 
until it comes to the closed internal os, with the umbilical cord passing 
through it, which has generally been supposed to be a circular con- 
traction of a portion of the body of the uterus. 

Encystment of the placenta, however, although more rarely, unques- 
tionablv takes place in a portion only of the body of the uterus 
(Fig. 152). Tnen apparently the placental site remains more or less 
paralyzed, with the piaceuta still attached, while the remainder of the 
body of the uterus contracts firmly, and thus encystment is produced. 

These irregular contractions of the uterus are by no means so common 
as our ohler authors supposed. When they do occur, I believe them 
almost invariably to depend on defective management of the third 
stage of labor. "The most frequent cause," says Rigby, 1 "is from 
over-anxiety to remove the placenta ; the cord is frequently pulled at, 
and at length the os uteri is excited to contract." While this is being 
done, no attempts are probably beiug made to excite the fundus to 
proper action, and, therefore, the hour-glass contraction is established. 

1 Rigby's Midwifary, p. 222. 



438 



LABOR. 



Johnstone 1 has pointed out that in a large proportion of cases ergot 
has been given before the expulsion of the placenta. Duncan says of 
this condition : " Hour-glass contraction cannot exist unless the parts 
above the contraction are in a state of inertia ; were the higher parts 
of the uterus even in moderate action, the hour-glass contraction would 
soon be overcome." 2 If placental expression were always employed, if 
it were the rule to effect the expulsion of the placenta by a vis a tergo, 
instead of extracting it by a vis a fronte, I feel confident that these 
irregular and spasmodic contractions — of the influence of which in 
producing hemorrhage there can be no question — would rarely, if ever, 
be met with. It is to be observed that, even in these cases, it is not 
because the uterus is in a state of partial contraction, but because it is 
in a state of partial relaxation, that hemorrhage ensues. 

Fig. 152. 





Irregular contraction of the uterus, with encystment of the placenta 



Placental Adhesions. — Adhesions of the placenta to the uterine 
parietes may cause hemorrhage, especially if they be partial and the 
remainder of the placenta be detached. The frequency of these has 
been over-estimated. Many cases believed to be examples of adherent 
placentae are, in reality, only cases of placentae retained from uterine 
inertia. The experience of all who see much midwifery will probably 
corroborate the observation of Braun, that " abnormal adhesion and 
hour-glass contraction are more frequently encountered in the expe- 
rience of the young practitioner, and they diminish in frequency in 
direct ratio to increasing years." 3 The cause of adhesion is often 
obscure, but it most probably results from a morbid state of the 
decidua, which is produced by antecedent disease of the uterine mucous 
membrane ; then the adhesion is apt to recur in subsequent pregnancies. 
The decidua is altered and thickened, and patches of calcareous and 
fibrous degeneration may be often found on the attached surface of the 
placenta. Most frequently the placenta is only partially adherent; 



i Glasgow Med. Journ., vol. xxvii. 188. 
2 Researches in Obstetrics, p. 389. 



Braun's Lectures, 1869. 



HEMORRHAGE AFTER DELIVERY. 439 

patches of it remain firmly attached to the uterus, while the rest is 
separated; hence the uterine walls remain relaxed and hemorrhage 
frequently follows. The diagnosis and management of these very 
troublesome cases will be found described under the head of treatment 
(p. 443). 

Finally, I think it must be admitted that there are some women 
who really merit the appellation of " Flooders" which has been applied 
to them, and Avho, do what Ave may, have the most extraordinary ten- 
dency to hemorrhage after delivery. I do not think that these cases, 
however, are by any means so common as some have supposed. I have 
attended several patients who have nearly lost their lives from post- 
partum hemorrhage in former labors, some who have suffered from it 
in every preceding confinement, and I have only met with two cases 
in which the assiduous use of preventive treatment failed to avert it. 
In these (one of which I have elsewhere published in detail 1 ), in spite 
of all my efforts, I could not succeed in keeping up uterine contraction, 
and the patients would certainly have lost their lives were it not for 
the means which modern improvements have fortunately placed at our 
disposal for producing thrombosis in the mouths of the bleeding 
vessels. The nature of these rare cases requires further investigation ; 
possibly they may, to some extent, be the subjects of the so-called 
hemorrhagic diathesis. 

The loss of blood may commence immediately after the birth of the 
child, before the expulsion of the placenta, or not until some time 
afterward, when the contracted uterus has again relaxed. It may 
commence gradually or suddenly ; in the latter case it may begin with 
a gush, and in the worst form the bedclothes, the bed, and even the 
floor, are deluged with the blood which, it is no exaggeration to say, 
is pouring from the patient. If now the hand be placed on the abdo- 
men, we shall miss the hard round ball of the contracted uterus, which 
will be found soft and flabby, or we may even be unable to make out 
its contour at all. If the hemorrhage be slight, or if we succeed in 
controlling it at once, no serious consequences follow ; but if it be ex- 
cessive, or if Ave fail to check it, the graA T est results ensue. 

There are few sights more appalling to Avitness than one of the Avorst 
cases of post-partum hemorrhage. The pulse becomes rapidly affected, 
and may be reduced to a mere thread, or it may become entirely im- 
perceptible. Syncope often comes on — not in itself always an un- 
favorable occurrence, as it tends to promote thrombosis in the venous 
sinuses. Or, short of actual syncope, there may be a feeling of intense 
debilitv and faintness. Extreme restlessness soon supervenes, the 
patient throws herself about the bed, tossing her arms wildly above 
her head; respiration becomes gasping and sighing, the "besoin de 
respirer" is acutely felt, and the patient cries out formoreair; the skin 
becomes deadly cold, and covered with profuse perspiration; if the 
hemorrhage continue unchecked, we next may have complete loss of 
vision, jactitation, convulsions, and death. 

Formidable as such symptom- are, it is satisfactory t<> know that 

Obst Journ., vol. i. p. 89. 



440 LABOR. 

recovery often takes place, even when the powers of life seem reduced 
to the lowest ebb. If we can check the hemorrhage while there is 
still some power of reaction left, however slight, we may not unreason- 
ably hope for eventual recovery. The constitution, however, may 
have received a severe shock, and it may be months, or even years, 
before the patient recovers from the effects of only a few minutes* 
hemorrhage. A death-like pallor frequently follows these excessive 
losses, and the patient often remains blanched and exsanguine for a 
long time. 

Preventive Treatment. — The preventive treatment of post-partum 
hemorrhage should be carefully practised in every case of labor, how- 
ever normal. If the practitioner make a habit of never removing his 
hand from the uterus after the birth of the child until the placenta is 
expelled, and of keeping up continuous uterine contraction for at least 
half an hour after delivery is completed, not necessarily by friction on 
the fundus, but by simply grasping the contracted womb with the 
palm of the hand and preventing its undue relaxation, cases of post- 
partum flooding will seldom be met with. As a rule we should not, I 
think, apply the binder until at least that time has elapsed. The 
binder is an effective means of keeping up, but not of producing, con- 
traction, and it should never be trusted to for the latter purpose. If 
it be put on too soon, the uterus may relax under it, and become filled 
with clots without the practitioner knowing anything about it ; whereas, 
this cannot possibly take place as long as the uterine globe is held in 
the hollow of the hand. I have seen more than one serious case of 
concealed hemorrhage result from the too common habit of putting on 
the binder immediately after the removal of the placenta. I believe 
also, as I have formerly said, that it is thoroughly good practice to 
administer a full dose of the liquid extract of ergot in all cases after 
the placenta has been expelled, to insure persistent contraction and to 
lessen the chance of blood-clots being retained in utero. 

These are the precautions which should be used in all cases alike ; 
but when we have reason to fear the occurrence of hemorrhage, from 
the history of previous labors or other cause, special care should be 
taken. Lombe Atthill 1 advises that in such cases the patient should 
take a mixture containing small doses of the liquid extract of ergot 
and liquor strychnise for some weeks before labor. Lauder Bruuton 2 
says that in cases of hemorrhagic diathesis operations have been ren- 
dered almost bloodless by administering chloride of calcium, which has 
the effect of promoting the coagulability of the blood. I am not aware 
that this drug has been tried in midwifery practice, but in known 
" flooders " it might be worth while giving one or two 10-grain doses 
at short intervals after labor has begun. Ergot should be given, and 
preferably in the form of the subcutaneous injection of ergotine, before 
the birth of the child, when the presentation is so far advanced that 
we estimate that labor will be concluded in from ten to twenty minutes, 
as we can hardly expect the drug to produce any effect in less time. 
Particular attention, moreover, should then be paid to the state of the 

1 "The Anticipation of Pnst-Partum Hemorrhage," Brit. Med. Journ., March 6, 1897 

2 The Action of Medicines, p. »3. 



HEMORRHAGE AFTER DELIVERY. 441 

uterus. Every means should be taken to insure regular and strong 
contraction, and it is advisable to rupture the membranes early, as soon 
as the os is dilated or dilatable, to insure strouger uterine action. If 
any tendency to relaxation occur after delivery, a piece of ice should 
be passed into the vagina or into the uterus. Should coagula collect in 
the uterus, they may be readily expelled by firm pressure on the 
fundus, and the finger should be passed occasionally up to the cervix, 
and any which are felt there should be gently picked away. 

"We should be specially on our guard in all cases in which the pulse 
does not fall after delivery. If it beat at 100 or more some ten minutes 
or a quarter of an hour after the birth of the child, hemorrhage not 
unfrequentlv follows ; and hence it is a good practical rule, which may 
save much trouble, that a patient should never be left unless the pulse 
has fallen to its natural standard. 

Curative Treatment. — As there are only two means which Nature 
adopts in the prevention of post-partum hemorrhage, so the remedial 
measures also may be divided into two classes : 1. Those which act 
by the production of uterine contraction. 2. Those which act by pro- 
ducing thrombosis in the vessels. Of these the first are the most 
commonly used ; and it is only in the worst cases, in which they have 
been assiduously tried and have failed, that we resort to those coming 
under the second heading. 

The patient should be placed on her back, in which position we can 
more readily command the uterus, as well as attend to her general 
state. If the uterus be found relaxed and full of clots, by firmly 
grasping it in the hand contraction may be evoked, its contents ex- 
pelled, and further hemorrhage at once arrested. Should this fortu- 
natelv be the case, we must keep up contraction by gently kneading 
the uterus, until we are satisfied that undue relaxation will not recur. 

The powerful influence of friction in promoting contraction cannot 
be doubted, and nothing will replace it ; no doubt it is fatiguing, but 
as long as it is effectual it must be kept up. No roughness should be 
used, as we might produce subsequent injury, but it is quite possible to 
use considerable pressure without any violence. 

Another method of applying uterine pressure has been strongly 
advocated by Dr. Hamilton, of Falkirk, and it may be serviceable 
where there is a constant draining from the uterus, and a capacious 
pelvis. It consists in passing the fingers of the right hand high up 
into the posterior cul-de-sac of the vagina, so as to reach the posterior 
surface of the uterus, while counter-pressure is exercised by the left 
hand through the abdomen. The anterior and posterior walls of the 
uterus are thus closely pressed together. 

During the time that pressure is being applied, attention can be paid 
to general treatment ; and in giving his directions to the bystanders 
the practitioner should be calm and collected, avoiding all hurry and 
excitement. A full dose of ergot should be administered, and if one 
have already been given, it should be repeated. We cannot, however, 
look upon ergot as anything but a useful accessory, and it is one which 
requires considerable time to operate. The hypodermic use of ergotine 
offers the double advantage, in severe cases, of acting with, greater 



442 LABOR, 

power, and much more rapidly, than the usual method of administra- 
tion. It should, therefore, always be used in preference. An aqueous 
solution of ergotiue, ^Jo" °^ a g ram m 10 minims, has been highly re- 
commended by Chahbazain, of Paris, as acting more energetically, and, 
it has seemed to me, 1 to have had a good effect. 

The sudden flow will probably have produced exhaustion and a 
tendency to syncope, and the administration of stimulants will be 
necessary. The amount must be regulated by the state of the pulse 
and the degree of exhaustion. There is no more absurd mistake, how- 
ever, than implicitly relying on the brandy bottle to check post-partum 
hemorrhage. In the worst cases absorption is in abeyance, and brandy 
may be poured down in abundance, the practitioner believing that he 
is rousing his patient, while he is, in fact, only filling the stomach with 
a quantity of fluid which is eventually thrown up unaltered. I have 
more than once seen symptoms, produced by the over-free use of brandy 
in slight floodings, which were certainly not those of hemorrhage. I 
remember on one occasion being summoned by a practitioner, with 
a view to transfusion, to a patient who was said to be insensible and 
collapsed from hemorrhage. I found her, indeed, unconscious; but 
with a flushed face, a bounding pulse, a firmly contracted uterus, and 
deep stertorous breathing. On inquiry I ascertained that she had 
taken an enormous quantity of brandy, which had brought on the 
coma of profound intoxication, while the hemorrhage had obviously 
never been excessive. 

The hypodermic injection of sulphuric ether is a remedy of great 
value as a powerful stimulant in cases in which exhaustion is very 
great. It has the advantage of acting rapidly, and of being capable 
of administration when the patient is unable to swallow. A fluid 
drachm may be injected into the nates, or thigh, and the injection may 
be repeated as the state of the patient may require. 

Injection of Saline Infusion. — The subcutaneous injection of a 
saline infusion has been strongly recommended by Munchmeyer 2 in all 
cases in which the loss of blood has been great. The solution is made 
by dissolving a teaspoonful of common salt in a pint of water at 
100° F., and it can be injected into the loose subcutaneous tissue of 
the loin or buttock by an improvised apparatus made by a glass funnel, 
a piece of india-rubber tubing, and an ordinary aspirating needle, 
sterilized by boiling. A simpler and very efficacious plan, from which 
I have had excellent results, is to inject a pint of the same solution 
into the rectum. 

The window should be thrown widely open, to allow a current of 
fresh cold air to circulate freely through the room. The pillows should 
be removed, the head kept low, and the patient should be assiduously 
fanned. It is often found to be useful to raise the feet of the bed on 
blocks of wood, or books, so as to have the head lower than the pelvis. 
This will favor the current of blood to the head, and lessen the ten- 
dency to syncope. 

If bleediug continue, or if it commence before the placenta is ex- 

1 Obst. Trans., vol. xxiv. p. 286. 

2 Munchmeyer: Areh. f Gynak., Bd. xxxiv. Heft 3. 



HEMORRHAGE AFTER DELIVERY. 443 

pelled, the hand should be carefully and gently passed into the uterus, 
and its cavity cleared of its contents. The more presence of the hand 
within the uterus is a powerful inciter of uterine action. AVhen the 
placenta is retained it is the more essential, as the hemorrhage cannot 
possibly be checked as long as the uterus is distended by it. During 
the operation the uterus should be supported by the left hand externally, 
and, by using the two hands in concert, the chances of injuring the 
textures are greatly lessened. 

Treatment of Hour-glass Contraction. — If the so-called " hour- 
glass contraction " be present, or if the placenta be morbidly adherent, 
the operation will be more difficult, and will require much judgment 
and care. The spasmodic contraction of the inner os in the former 
case may generally be overcome by gentle and continuous pressure of 
the fingers passed within the contraction, while the uterus is supported 
from without. By this means, too, further hemorrhage can in most 
cases be controlled until the spasm is sufficiently relaxed to admit of 
the passage of the hand. 

Signs of Adherent Placenta. — There are no very reliable signs to 
indicate morbid adhesion of the placenta, previous to the introduction 
of the hand. The following are the symptoms as laid down by Barnes, 
any of which might, however, accompany non-detaehment of the 
placenta unaccompanied by adhesion : " You may suspect morbid 
adhesion if there have been unusual difficulty in removing the placenta 
in previous labors ; if during the third stage the uterus contracts at 
intervals firmly, each contraction being accompanied by blood, and 
yet, on following up the cord, you feel the placenta in utero ; if, on 
pulling on the cord, two fingers being pressed into the placenta at the 
root, you feel the placenta and uterus descend in one mass, a sense of 
dragging pain being elicited ; if during a pain the uterine tumor does 
not present a globular form, but is more prominent than usual at the 
place of placental attachment." 1 

Treatment of Adherent Placenta. — The artificial removal of an 
adherent placenta is always a delicate and anxious operation, which, 
however carefully performed, must of necessity expose the patient to 
the risk of injury to the uterine structures, and of leaving behind por- 
tions of placental tissue, which may give rise to secondary hemorrhage 
or sapraemia. The cord will guide the hand to the site of attachment, 
and the fingers must be very gently insinuated between the lower edge 
of the placenta and the uterine wall ; or, if a portion be already 
detached, we may commence to peel off the remainder at that spot. 
Supporting the uterus externally, we carefully pick off as much as 
possible, proceeding with the greatest caution, as it is by no means easy 
to distinguish between the placenta and the uterus. At the best, it is 
far from easy to remove all, and it is wiser to separate only what we 
readily can than to make too protracted efforts at complete detachment. 
When it is found to be impossible to detach and remove the whole or 
a great part of the placenta, we cannot but look upon the further 
progress of the case with considerable anxiety. The retained pom ions 

1 Obstetric Operations, p. 440. 



444 LABOR. 

may be, ere long, spontaneously detached and expelled, or they may 
decompose and give rise to fetid discharge and septic infection. Such 
cases must be treated by antiseptic intra-uterine injections, so as to 
lessen the risk of absorption as much as possible ; but until the retained 
masses have been expelled, and the discharge has ceased, the patient 
must be considered to be in considerable danger. In a few rare cases, 
there is reason to believe that considerable masses of retained placental 
tissue have been entirely absorbed. It is difficult to understand so 
strange a phenomenon, but several well-authenticated cases are re- 
corded in which there seems no reason to doubt that the retained 
placenta was removed in this way. 1 

Various means are used for exciting uterine contraction by reflex 
stimulation. Amongst the most important of these is cold. In 
patients who are not too exhausted to respond to the stimulus applied, 
it is of extreme value. But, to be of use, it should be used intermit- 
tently, and not continuously. Pouring a stream of cold water from a 
height on the abdomen is a not uncommon, but bad practice, as it 
deluges the patient and bedding in water, which may afterward act 
injuriously. Flapping the lower part of the abdomen with a wet 
towel is less objectionable. Ice can generally be obtained, and a piece 
should be introduced into the uterus. This is a very powerful haemo- 
static, and often excites strong action when other means fail. I con- 
stantly employ it, and have never seen any bad results follow. A 
large piece of ice may also be held over the fundus, and removed, 
and reapplied from time to time. Iced water may be injected into 
the rectum. A very powerful remedy is washing out the uterine 
cavity with a stream of cold water, by means of the vaginal pipe of a 
Higginson's syringe carried up to the fundus. Another means of 
applying cold, said to be very effectual, is the application of the ether 
spray, such as is used for producing local anaesthesia, over the lower 
part of the abdomen. 2 All these remedies, however, depend for their 
good results on the fact of the patient being in a condition to respond 
to stimulus ; and their prolonged use, if they fail to excite contraction 
rapidly, will certainly prove injurious. Rigby used to look upon the 
application of the child to the breast as one of the most certain inciters 
of uterine action. It may be of service after the hemorrhage has been 
checked, in keeping up tonic contraction, and should therefore not be 
omitted ; but we certainly cannot waste time in inducing the child to 
suck in the face of the actual emergency. 

Intra-uterine injection of hot water, at a temperature of from 100° 
to 120°, has been highly recommended as a powerful means of arrest- 
ing postpartum hemorrhage, often proving effectual when all other 
treatment has failed. The number of published cases in which it 
has proved of great value is now considerable. The late master of 
the Rotunda, Dr. Lombe Atthill, has recorded sixteen cases 3 in which it 
checked hemorrhage at once, in many of which ergot, ice, and other 
means had failed. He speaks of it as especially useful in those trouble- 

i See an interesting paper by Dr. Thrush on " Retention of the Piacenta in Labor at Term," 
Amer. Journ. of Obstet., vol. x. pp. H89, 506. 
-' Griffiths: Practitioner, vol. xviii. p. 116. 3 Lancet, February 9, 1878. 



HEMORRHAGE AFTER DELIVERY. 445 

some cases in which the uterus alternately relaxes aud hardens, and 
resists all our efforts to produce permanent contraction. Its superiority 
to cold water has been well shown by Milne Murray 1 by means of ex- 
periments on pregnant and non-pregnant rabbits, which proved that 
while cold applications produce a temporary contraction, when applied 
for any length of time they rapidly exhaust the excitability of the uterine 
muscle, while the reverse effect is produced when hot water is used. 
My own experience of this treatment is very favorable. I have now 
used it in many cases, in some of which the tendency to hemorrhage 
was very great, and in every instance it has at once produced strong 
uterine action and instantly checked the flow. It is, moreover, much 
more agreeable to the patient than cold applications. It is advisable 
to add a few drops of creolin to the hot water, which is in itself a 
good antiseptic, and is said to be also a powerful styptic. I think it 
cannot be doubted that we have in these warm irrigations a valuable 
addition to our methods of treating uterine hemorrhage. 

The late Dr. Earle pointed out 2 that a distended bladder often pre- 
vents contraction, and to avoid the possibility of this the catheter 
should be passed. 

Since 1887 plugging the uterine cavity with iodoform gauze, or, 
when this is not at hand, with pledgets of cotton- wool soaked in 
carbolic solution, has been strongly advocated in Germany, chiefly by 
Diihrssen, 3 but since the publication of his paper a large number of 
successful cases have been published 4 in which this treatment has 
been adopted, so that it must be admitted as a useful resource in cer- 
tain intractable cases. It seems to act in two ways : first, by exciting 
energetic and continuous uterine contractions; and next, by direct 
pressure on the bleeding part. In applying the plugs, the patient 
should be placed on her back, the cervix drawn down with a volsella, 
and long strips of gauze passed up to the fundus with ovuni forceps, 
until the uterine cavity is completely packed. The vagina should be 
subsequently plugged with pledgets of cotton-wool soaked in glycerin 
or carbolized water and dusted with iodoform. The plugs may be 
allowed to remain in the uterus from eight to twelve hours, by which 
time all risk of recurrence of the hemorrhage will be at an end. I 
have no personal experience of this treatment, but the evidence in its 
favor is strong. It is clearly one which can only be resorted to in very 
intense cases of hemorrhage when all other means have failed. It will 
obviously be essential to carefully watch the uterus, to make sure that 
blood is not escaping into and distending its cavity above the plug. 
If the uterine cavity should be only partially or ineffectually filled, 
concealed internal hemorrhage might very readily be going on without 
the practitioner's knowledge. 

Compression of the abdominal aorta is highly thought of by many 
Continental authorities, but it is little known or practised in this 
country. It has been objected to by some on the theoretical ground 
that the hemorrhage is chiefly venous, not arterial, and that it would 
only favor the reflux of venous blood into the vena cava. Cazeaux 

1 Edin. Med. Jonrn., 1S86-87, pp. 131. 215. 2 Earle : Flooding after Delivery, p. 1G3. 

3 Volkmannische Sammluug, No. 347. * See Year-book of Treatment, 1891. 



446 LABOR. 

points out that, on account of the close anatomical relations between 
the aorta and the vena cava, it is hardly possible to compress one 
vessel without the other. The backward flow of blood, therefore, 
through the vena cava may also be thus arrested. There is strong 
evidence in favor of the occasional utility of compression. Its chief 
recommendation is that it can be practised immediately, and by an 
assistant, w T ho can be shown how to apply the pressure. It is most 
likely to prove useful in sudden and severe hemorrhage, and, if it 
only control the loss for a few moments, it gives us time to apply 
other methods of treatment. As a temporary expedient, therefore, it 
should be borne in mind, and adopted when necessary. It has the 
great advantage of supplementing, without superseding, other and 
more radical plans of treatment. The pressure is very easily applied, 
on account of the lax state of the abdominal walls. The artery can 
readily be felt pulsating above the fundus uteri, and can be com- 
pressed against the vertebrae by three or four fingers applied length- 
wise. Baudelocque, who was a strong advocate of this procedure, 
stated that he had, on several occasions, controlled an otherwise 
intractable hemorrhage in this way, and that he, on one occasion, kept 
up compression for four consecutive hours. Cazeaux believes that 
compression of the aorta may have a further advantageous effect in 
retaining the mass of the blood in the upper part of the body, and 
thus lessening the tendeucy to syncope and collapse. If an aortic 
tourniquet, such as is used for compressing the vessel in cases of 
aneurism, could be obtained, it might be used with advantage in such 
cases. 

If a battery is at hand the faradic current may be used, and it is said 
to be a very powerful agent in inducing uterine contraction, one pole 
being introduced into the uterus, the other applied over it through the 
abdominal parietes. 

When the hemorrhage has been excessive, and there is profound 
exhaustion, firm bandaging of the extremities, by preference with 
Esmarch's elastic bandages if they can be obtained, may be advan- 
tageously adopted, with the view of retaining the blood as much as 
possible in the trunk, and thus lessening the tendency to syncope. As 
a temporary expedient in the worst class of cases it may occasionally 
prove of service. 

Supposing these means fail, and the uterus obstinately refuses to 
contract in spite of all our efforts — and, do what we may, cases of this 
kind will occur — the only other agent at our command is the applica- 
tion of a powerful styptic to the bleeding surface to produce throm- 
bosis in the vessels. " The latter," says Dr. Ferguson, 1 alluding to 
this means of arresting hemorrhage, " appears to be the sole means of 
safety in those cases of intense flooding in which the uterus flaps about 
the hand like a wet towel. Incapable of contraction for hours, yet 
ceasing to ooze out a drop of blood, there is nothing apparently be- 
tween life and death but a few soft coagula plugging up the sinuses." 
These form but a frail barrier indeed, but the experience of all who 

1 Preface to Gooch " On Diseases of Women." p. xlii. New Sydenham Society, 1859. 



HEMORRHAGE AFTER DELIVERY. 447 

have used the injection of a solution of perehloride of iron in such 
cases proves that they are thoroughly effectual, and their introduction 
into practice is one of the greatest improvements in modern mid- 
wifery. Although this method of treating these obstinate cases is not 
new, since it was practised long ago in Germany, its adoption in this 
country is unquestionably due to the energetic recommendation of Dr. 
Barnes. The dangers of the practice have been strongly insisted on, 
and with a degree of acrimony that is to be regretted, but I know of 
only one published case in which its use has been followed by any 
evil effects. Its extraordinary power, however, of instantly checking 
the most formidable hemorrhage has been demonstrated by the unani- 
mous testimony of all who have tried it. As it is not proposed by 
anyone that this means of treatment should be employed until all 
ordinary methods of evoking contraction have failed, and as, in cases 
of this kind, the lives of the patients are of necessity imperilled, we 
should be fully justified in adopting it, even if its possibly injurious 
effects had been much more certainly proved. It is surely at any time 
justifiable to avoid a great and pressing peril by running a possible 
chance of a less one. Whenever, therefore, we have tried the plans 
above indicated in vain, no time should be lost in resorting to this 
expedient. Xo practitioner should attend a case of midwifery without 
having the necessary styptic with him. The best and most easily 
obtainable form of using the remedy is the "liquor ferri perchloridi 
fortior" of the London Pharmacopoeia, which should be diluted for 
use with six times its bulk of water. This is certainly better than a 
weaker solution. The vaginal pipe of a Higginson's syringe, through 
which the solution has once or twice been pumped to exclude the air, 
is guided by the baud to the fundus uteri, and the fluid injected gently 
over the uterine surface. The loose and flabby mucous membrane is 
instantaneously felt to pucker up, all the blood with which the fluid 
comes in contact is coagulated, and the hemorrhage is immediately 
arrested. I think it is of importance to make sure that the uterus and 
vagina are emptied of clots before injection. In the only cases in 
which I have seen any bad symptoms follow, this precaution had been 
neglected. The iron hardened all the coagula, which remained in utcro, 
and sapraemia supervened ; which, however, disappeared after the clots 
had been broken up and washed away by intra-uterine antiseptic in- 
jections. After we have resorted to this treatment, all further pressure 
on the uterus should be stopped. We must remember that we have 
now abandoned contraction as a haemostatic, and are trusting to throm- 
bosis, and that pressure might detach and lessen the coagula which are 
preventing the escape of blood. 

Other local astringents may be eventually found to be of use. 
Tincture of matico possibly might be serviceable, although I am not 
aware that it has been tried. The styptic properties of creolin have 
already been mentioned. Dupierris has advocated tincture of iodine, 
and has recorded twenty-four eases in which he employed it, in all 
without accident, and with a successful issue. Penrose 1 strongly 

1 Trans. Amer. Gyn. Sw., vol. iii. p. 148. 



448 LABOR. 

recommends common vinegar, which has the advantage of being 
always readily obtainable. He speaks highly of its haemostatic effect. 
He soaks a clean handkerchief in it, and introduces it by the hand 
into the uterine cavity, and squeezes it over the endometrium. He 
says : a The effect of the vinegar flowing over the sides of the cavity 
of the uterus and vagina is magical. The relaxed and flabby uterine 
muscle instantly responds. The organ assumes what is called its 
gizzard-like feel, shrinking down upon and compressing the operating 
hand, and in the vast majority of cases the hemorrhage ceases in- 
stantly." This is certainly worth trying before the iron solution, 
which is not, as we have seen, devoid of certain risks. 

Hemorrhage from Laceration of Maternal Structures. — A word 
may here be said as to the occasional dependence of hemorrhage after 
delivery on laceration of the cervix or other injury to the maternal 
soft parts. Duncan has narrated a case in which the bleeding came 
from a ruptured perineum. If hemorrhage continues after the uterus 
is permanently contracted, a careful examination should be made to 
astertain if any such injury exist. Most generally the source of bleed- 
ing is the cervix, and the flow can be readily arrested by swabbing 
the injured textures with a sponge saturated in a solution of the per- 
chloride. 

Secondary Treatment. — The secondary treatment of post-partuni 
hemorrhage is of importance. When reaction commences, a train of 
distressing symptoms often show themselves, such as intense and 
throbbing headache, great intolerance of light and sound, and general 
nervous prostration ; and, when these have passed away, w r e have to 
deal with the more chronic effects of profuse loss of blood. Nothing 
is so valuable in relieving these symptoms as opium. It is the best 
restorative that can be employed, but it must be administered in larger 
doses than usual. Thirty to forty drops of Battley's solution should 
be given by the mouth or in an enema. At the same time the patient 
should be kept perfectly still and quiet, in a darkened room, and the 
visits of anxious friends strictly forbidden. Strong beef-essence or 
gravy soup, milk, or eggs beaten up with milk, and similar easily 
absorbed articles of diet, should be given frequently, and in small 
quantities at a time. Stimulants will be required according to the 
state of the patient, such as warm brandy-and-water, port wine, etc. 
Rest in bed should be insisted on, and continued much beyond the 
usual time. Eventually the remedies which act by promoting the 
formation of blood, such as the various preparations of iron, will be 
found useful, and may be required for a length of time. 

Under the head of Transfusion, I have separately treated the appli- 
cation of that last resource in those desperate cases in which the loss 
of blood has been so excessive as to leave no other hope. 

Secondary Post-partum Hemorrhage. — In the majority of cases, 
if a few hours have elapsed after delivery without hemorrhage, we 
may consider the patient safe from the accident. It is by no means 
very rare, however, to meet with even profuse losses of blood coming 
on in the course of convalescence, at a time varying from a few hours 
or days up to several weeks after delivery. These cases are described 



HEMORRHAGE AFTER DELIVERY. 449 

as examples of secondary hemorrhage, and they have not received an 
at all adequate amount of attention from obstetric writers, inasmuch 
as they often give rise to very serious, and even fatal results, and are 
always somewhat obscure in their etiology and difficult to treat. We 
owe almost all our knowledge of this condition to an excellent paper 
by Dr. MeClintock, of Dublin, who has collected characteristic exam- 
ples from the writings of various authors, and accurately described the 
causes which are most apt to produce it. 

AVe must, in the first place, distinguish between true secondary hem- 
orrhage and profuse lochia! discharge continued for a longer time 
than usual. The latter is not a very uncommon occurrence, and is 
generally met with in cases in which involution of the uterus has 
been checked — as by too early exertion, general debility, and the like. 
The amount of the lochial discharge varies in different women. In 
some patients it habitually continues during the whole puerperal 
month, and even longer, but not to an extent which justifies us in 
including it under the head of hemorrhage. In such cases prolonged 
rest, avoidance of the erect posture, occasional small doses of ergot, 
and, it may be, after the lapse of some weeks, astringent injections of 
oak-bark or alum, will be all that is necessary in the way of treat- 
ment. 

True secondary hemorrhage is often sudden in its appearance and 
serious in its effects. MeClintock mentions six fatal cases, and Mr. 
Bassett, 1 of Birmingham, has recorded thirteen examples which came 
under his own observation, two of which ended fatally. 

The causes may be either constitutional, or some local condition of 
the uterus itself. 

Constitutional Causes. — Among the former are such as produce a 
disturbance of the vascular system of the body generally, or of the 
uterine vessels in particular. The state of the uterine sinuses, and the 
slight barrier which the thrombi formed in them offer to the escape 
of blood, readily explain the fact of any sudden vascular congestion 
producing hemorrhage. Thus mental emotions, the sudden assump- 
tion of the erect posture, any undue exertion, the incautious use of 
stimulants, a loaded condition of the bowels, or sexual intercourse 
shortly after delivery, may act in this way. MeClintock records the 
case of a lady in whom very profuse hemorrhage occurred on the 
twelfth day after labor, when sitting up for the first time. Feeling 
faint after suckling, the nurse gave her some brandy, whereupon a 
gush of blood ensued, " deluging all the bedclothes and penetrating 
through the mattress so as to form a pool on the floor." Here the 
erect position, the exquisite pain caused by nursing, and the stimulat- 
ing drink, all concurred to excite the hemorrhage. In another instance 
the flooding was traced to excitement produced by the sudden return 
of an old lover on the eighth day after labor. Moreau especially 
dwells on the influence of local congestion produced by a loaded con- 
dition of the rectum. Constitutional affections producing general 
debility and an impoverished state of the blood, probably also may 

1 Brit. Med. Journ.. vol. ii. p. 216, 491. 
29 



450 



LABOR. 



have the same effect. Blot specially mentions albuminuria as one of 
these, and Saboia states that in Brazil secondary hemorrhage is a com- 
mon symptom of miasmatic poisoning, and can only be cured by 
change of air and the free use of quinine. 1 

Local Causes. — Local conditions seem, however, to be the more 
frequent factors in the production of secondary hemorrhage. These 
may be generally classed under the following heads : 

i . Irregular and inefficient contraction of the uterus. 

2. Clots in the uterine cavity. 

3. Portions of retained placenta or membranes. 

4. Retroflexion of the uterus. 

5. Laceration or inflammatory state of the cervix. 

6. Thrombosis or hematocele of the cervix or vulva. 

7. Inversion of the uterus. 

8. Fibroid tumors or polypus of the uterus. 

The first four of these need only now be considered, the others being 
described elsewhere. 

Relaxation of the uterus and distention of its cavity by coagula may 
give rise to hemorrhage, although not so readily as immediately after 
delivery, for coagula of considerable size are often retained in utero for 
many days after labor. The uterus will be found larger than it ought 
to be, and tender on pressure. Usually the coagula are expelled with 
severe after-pains ; but this may not take place, and hemorrhage may 
ensue several days after delivery. Or there may be only a relaxed 
state of the uterus without retained coagula. Bassett relates four cases 
traced to these causes, and several illustrations will be found in 
McClintock's paper. Portions of retained placenta or membranes are 
more frequent causes. The retention may be due to carelessness on 
the part of the practitioner, especially if he have removed the placenta 
by traction, and failed to satisfy himself of its integrity. It may, 
however, often be due to circumstances entirely beyond his control ;. 
such as adherent placenta, which it is impossible to remove without 
leaving portions in utero, or more rarely placenta succenturia. In the 
latter case there is a small supplementary portion of placental tissue 
developed entirely separate from the general mass, and it may remain 
in utero without the practitioner having the least suspicion of its exist- 
ence. Portions of the membranes are very apt to be left in utero. It 
is to prevent this that they should be twisted into a rope, and extracted 
very gently after expression of the placenta. Hemorrhage from these 
causes generally does not occur until at least a week after delivery, and 
it may not do so until a much longer time has elapsed. In four cases 
recorded by Mr. Bassett, it commenced on the tenth, twelfth, four- 
teenth, and thirty-second day. It may come on suddenly, and con- 
tinue ; or it may stop, and recur frequently at short intervals. In my 
experience retention of portions of the placenta is very common after 
abortion, when adhesions are more generally met with than at term. In 
addition to the hemorrhage there is often a fetid discharge, due to de- 
composition of the retained portion, and possibly more or less marked 

1 Saboia : Traite des Accouchements, p, 819, 



HEMORRHAGE AFTER DELIVERY. 451 

septic symptoms, which may aid iu the diagnosis. The placenta or 
membranes may simply be lying loose as foreign bodies in the uterine 
cavity ; or they may be organically attached to the uterine walls, when 
their removal will not be so easily effected. 

Barnes has especially pointed out the influence of retroflexion of the 
uterus in producing secondary hemorrhage/ which seems to act by 
impeding the circulation at the point of flexion, and thus arresting the 
process of involution. 

Treatment. — In every case in which secondary hemorrhage occurs 
to any extent, careful investigation into the possible causes of the 
attack, and an accurate vaginal examination, are imperatively required. 
If it be due to general and constitutional causes only, we must insist 
on the most absolute rest on a hard bed in a cool room, and on the 
absence of all causes of excitement. The liquid extract of ergot will 
be very generally useful in 5j doses repeated every six hours. Mc- 
Clintock strongly recommends the tincture of Indian hemp, which 
may be advantageously combined with the ergot, in doses of ten or 
fifteen minims, suspended in mucilage. Astringent vaginal pessaries 
of matico or perchloride of iron may be used. Special attention should 
be paid to the state of the bowels, and if the rectum be loaded, it 
should be emptied by enemata. In more chronic cases a mixture of 
ergot, sulphate of iron, and small doses of sulphate of magnesia will 
prove very serviceable. This is more likely to be eifectual when the 
bleeding is of an atonic and passive character. McClintock speaks 
strongly in favor of the application of a blister over the sacrum. 
When the hemorrhage is excessive, more effectual local treatment will 
be required. Cazeaux advises plugging of the vagina. Although this 
cannot be considered so dangerous as immediately after delivery, inas- 
much as the uterus is not so likely to dilate above the plug, still it is 
certainly not entirely without risk of favoring concealed internal hem- 
orrhage. If it be used at all, the uterine cavity should be plugged 
with iodoform gauze as well as the vagina, and a firm abdominal pad 
should be applied, so as to compress the uterus; and the abdomen 
should be examined from time to time, to insure against the possibility 
of uterine dilatation. With these precautions the plug may prove of 
real value. In any case of really alarming hemorrhage I should be 
disposed rather to trust to the application of styptics to the uterine 
cavity. The injection of fluid in bulk, as after delivery, could not be 
safelv practised, on account of the closure of the os and the contraction 
of the uterus. But there can be no objection to swabbing out the 
uterine cavity with a small piece of sponge attached to a handle, and 
saturated with tincture of iodine or witli a solution of the perchloride 
of iron. There are few cases which will resist this treatment. 

If we have reason to suspect retained placenta or membranes, or if 
the hemorrhage continue or recur after treatment, a careful exploration 
of the interior of the womb will be essential. On vaginal examination, 
we may possibly feel a portion of the placenta protruding through the 
os, which can then be removed without difficulty. If the os be closed 

1 Obstetric Operations, p. 492. 



452 LABOR. 

it must be dilated with Hegar's dilators, and the uterus can then be 
thoroughly explored. This ought to be done under chloroform, as it 
cannot be effectually accomplished without introducing the whole hand 
into the vagina, which necessarily causes much pain. If the placenta 
or membranes be loose in the uterine cavity, they may be removed at 
once ; or if they be organically attached, they may be carefully picked 
off. The uterus should at the same time, as long as the os remains 
patulous, be thoroughly washed out with creolin and water, or with a 
1 in 2000 solution of perchloride of mercury, to diminish the risk of 
saprsemia. 

Retroflexion can readily be detected by vaginal examination, and 
the treatment consists in careful reposition with the hand, and the 
application of a large-sized Hodge's pessary. 



CHAPTEE XVI. 

KUPTURE OF THE UTERUS, ETC. 

Rupture of the uterus is one of the most dangerous accidents of 
labor, and until of late years it has been considered almost necessarily 
fatal and beyond the reach of treatment. Fortunately it is not of very 
frequent occurrence, although the published statistics vary so much 
that it is by no means easy to arrive at any conclusion on this point. 
The explanation is, no doubt, that many of the tables confound partial 
and comparatively unimportant lacerations of the cervix and vagina 
with rupture of the body and fundus. It is only in large lying-in 
institutions, where the results of cases are accurately recorded, that 
anything like reliable statistics can be gathered, for in private practice 
the occurrence of so lamentable an accident is likely to remain unpub- 
lished. To show the difference between the figures given by authori- 
ties, it may be stated that, while Burns calculates the proportion to be 
1 in 940 labors, Ingleby fixes it as 1 in 1300 or 1400, Churchill as 1 
in 1331, and Lehmann as 1 in 2433. Dr. Jolly, of Paris, has pub- 
lished an excellent thesis containing much valuable information. 1 He 
finds that out of 782,741 labors, 230 ruptures, excluding those of the 
vagina or cervix, occurred — that is, 1 in 3403. 

Lacerations may occur in any part of the uterus — the fundus, the 
body, or the cervix. Those of the cervix are comparatively of small 
consequence, and occur, to a slight extent, in almost all first labors. 
Only those which involve the supra-vaginal portion are of really serious 
import. Ruptures of the upper part of the uterus are much less fre- 
quent than of the portion near the cervix ; partly, no doubt, because 
the fundus is beyond the reach of the mechanical causes to which the 

1 Rupture Uterine pendant le Travail, Paris, 1873. 



RUPTURE OF THE UTERUS. 453 

accident can not unfrequently be traced, and partly because the lower 
third of the organ is apt to be compressed between the presenting 
part and the bony pelvis. The site of placental insertion is said by 
Madame La Chapelle to be rarely involved in the rupture, but it does 
not always escape, as numerous recorded cases prove. The most fre- 
quent seat of rupture is near the junction of the body and neck, either 
anteriorly or posteriorly, opposite the sacrum, or behind the symphysis 
pubis ; but it may occur at the sides of the lower segment of the uterus. 
In some cases the entire cervix has been torn away, and separated in 
the form of a ring. 

The laceration may be partial or complete, the latter being the more 
common. The muscular tissue alone may be torn, the peritoneal coat 
remaining intact ; or the converse may occur, and then the peritoneum 
is often fissured in various directions, the muscular coat being unim- 
plicated. The extent of the injury is very variable, in some cases 
being only a slight tear, in others forming a large aperture, sufficiently 
extensive to allow the foetus to pass into the abdominal cavity. The 
direction of the laceration is as variable as the size, but it is more fre- 
quently vertical than transverse or oblique. The edges of the tear are 
irregular and jagged ; probably on account of the contraction of the 
muscular fibres, which are frequently softened, infiltrated with blood, 
and even gangrenous. Large quantities of extravasated blood will be 
found in the peritoneal cavity ; such hemorrhage, indeed, being one of 
the most important sources of danger. 

Causes. — The causes are divided into predisposing and exciting; and 
the progress of modern research tends more and more to the conclusion 
that the cause which leads to the laceration could only have operated 
because the tissue of the uterus was in a state predisposed to rupture, 
and that it would have had no such effect on a perfectly healthy organ. 
What these predisposing changes are, and how they operate, is yet far 
from being known, and the subject offers a fruitful field for pathological 
investigation. 

It is generally believed that lacerations are more common in mul- 
tipara than in primiparse. Tyler Smith contended that ruptures are 
relatively as common in first as in subsequent labors, while Bandl 1 
found that only 64 cases out of 546 ruptures were in primiparse. 
Statistics are not sufficiently accurate or extensive to justify a positive 
conclusion, but it is reasonable to suppose that the pathological changes 
presently to be mentioned as predisposing to laceration are more likely 
to be met with in women whose uteri have frequently undergone the 
alteration attendant on repeated pregnancies. Age seems to have con- 
siderable influence, as a large proportion of cases have occurred in 
women between thirty and forty years of age. 

Alterations in the tissues of the uterus are probably of very 
great importance in predisposing to the accident, although our infor- 
mation on this point is far from accurate. .Among these are morbid 
states of the muscular fibres, the result of blows and contusions during 
pregnancy; premature fatty degeneration of the muscular tissues, an 

1 Ueber Ruptur der Gebiir mutter. Wien, 1875. 



454 LABOR. 

anticipation, as it were, of the normal involution after delivery ; fibroid 
tumors or malignant infiltration of the uterine walls, which either 
produce a morbid state of the tissues, or act as an impediment to the 
expulsion of the foetus. The importance of such changes has been 
specially dwelt on by Murphy in England and by Lehmann in 
Germany, and it is impossible not to concede their probable influence 
in favoring laceration. However, as yet these views are founded more 
on reasonable hypothesis than on accurately observed pathological facts. 

Another and very important class of predisposing causes are those 
which lead to a want of proper proportion between the pelvis and the 
foetus. 

Deformity of the pelvis has been very frequently met with in 
cases in which the uterus has ruptured. Thus out of 19 cases carefully 
recorded by Eadford, 1 the pelvis was contracted in 11, or more than 
one-half. Radford makes the curious observation that ruptures seem 
more likely to occur when the deformity is only slight, and he ex- 
plains this by supposing that in slight deformities the lower segment 
of the uterus engages in the brim, and is, therefore, much subjected to 
compression ; while in extreme deformity the os and cervix uteri 
remain above the brim, the body and fundus of the uteri hanging 
down between the thighs of the mother. This explanation is reason- 
able; but the rarity with which ruptured uterus is associated with 
extreme pelvic deformity may rather depend on the infrequency of 
advanced degrees of contraction. 

Bandl, who has made the most important of modern contributions 
to our knowledge of the subject, points out that rupture nearly always 
begins in the lower segment of the uterus, which becomes abnormally 
stretched and distended w T hen from any cause the expulsion of the foetus 
is delayed. The upper portion of the uterus becomes, at the same 
time, retracted and much thickened (see Fig. 153). As the pains con- 
tinue, the stretching of the lower segment, called by Spiegelberg the 
" obstetrical cervix," becomes more and more marked, until at last its 
fibres separate and a laceration is established. The line of demarcation 
between* the thickened body and the distended lower segment, known 
as the ring of Bandl, can, in such cases, be occasionally made out by 
palpation above the pubes. 

Amongst the causes of disproportion depending on the foetus are 
either malpresentation, in which the pains cannot effect expulsion, or 
undue size of the presenting part. In the latter way may be explained 
the observation that rupture is more frequently met with in the deliv- 
erv of male than of female children, on account, no doubt, of the larger 
size of the head in the former. The influence of intra-uterine hydro- 
cephalus was first prominently pointed out by Sir James Simpson, 2 
who states that out of seventy-four cases of intra-uterine hydrocephalus 
the uterus ruptured in sixteen. In all such cases of disproportion, 
whether referable to the pelvis or foetus, rupture is produced in a two- 
fold manner — either by the excessive and fruitless uterine contractions, 
which are induced by the efforts of the organ to overcome the obstacle; 

» Obst. Trans., vol. viii. p. 150. 2 Selected Obst.,- Works, p. 385. 



RUPTURE OF THE UTERUS. 



455 



or by the compression of the uterine tissue between the presenting part 
and the bony pelvis, leading to inflammation, softening, and even 
gangrene. 

The proximate cause of rupture may be classed under two heads — 
mechanical injury and excessive uterine contraction. Under the former 
are placed those uncommon cases in which the uterus lacerates as the 
result of some injury in the latter months of pregnancy, such as blows, 
falls, and the like. Not so rare, unfortunately, are lacerations pro- 
duced by unskilled attempts at delivery on the part of the medical 
attendant, such as by the hand during turning, or by the blades of the 
forceps. Many such cases are on record, in which the accoucheur has 

Fig. 153. 




Illustrating the dangerous thinnin? of the lower segment of the uterus owing to non-descent 
of the head in a case of intra-uterine hydrocephalus (After Ban'dl.) 

used force and violence, rather than skill, in his attempts to overcome 
an obstacle. That such unhappy results of ignorance are not so un- 
common as they ought to be is proved by the figures of Jolly, who has 
collected seventy-one cases of rupture during podalic version, thirty- 
seven caused by the forceps, ten by the cephalotribe, and thirty during 
other operations the precise nature of which is not stated. 1 The modus 
operandi of protracted and ineffectual uterine contractions, as a proxi- 
mate cause of rupture, is sufficiently evident, and need not be dwelt on. 
It is necessary to allude, however, to the effect of ergot, incautiously 
administered, as a producing cause. There is abundant evidence that 

1 Op. Cit., p. 38. 



453 LABOR. 

the injudicious exhibition of this drug has often been followed by 
laceration of the unduly stimulated uterine fibres. Thus, Trask, talk- 
ing of the subject, says that Meigs had seen three cases, and Bedford 
four, distinctly traceable to this cause. Jolly found that ergot had 
been administered largely in thirty-three cases in which rupture 
occurred. 

Premonitory Symptoms. — Some have believed that the impending 
occurrence of rupture could frequently be ascertained by peculiar pre- 
monitory symptoms, such as excessive and acute crampy pains about 
the lower part of the abdomen, due to the compression of part of the 
uterine walls. These are far too indefinite to be relied on, and it is 
certain that the rupture generally takes place without any symptoms 
that would have afforded reasonable grounds for suspicion. 

General Symptoms. — The symptoms are often so distinct and 
alarming as to leave no doubt as to the nature of the case. Not infre- 
quently, however, especially if the laceration be partial, they are by 
no means so well marked, and the practitioner may be uncertain as to 
what has taken place. In the former class of cases a sudden excruci- 
ating pain is experienced in the abdomen, generally during the uterine 
contractions, accompanied by a feeling, on the part of the patient, of 
something having given way. In some cases this has been accom- 
panied by an audible sound, which has been noticed by the bystanders. 
At the same time there is generally a considerable escape of blood from 
the vagina, and a prominent symptom is the sudden cessation of the 
previously strong pains. Alarming general symptoms soon develop, 
partly due to shock, partly to loss of blood, both external and internal. 
The face exhibits the greatest suffering, the skin becomes deadly cold 
and covered with a clammy sweat, and fainting, collapse, rapid feeble 
pulse, hurried breathing, vomiting, and all the usual signs of extreme 
exhaustion quickly follow. 

Abdominal palpation and vaginal examination both afford character- 
istic indications in well-marked cases. If the child, as often happens, 
has escaped entirely, or in great part, into the abdominal cavity, it 
may be readily felt through the abdominal walls ; while in the former 
case, the partially contracted uterus may be found separate from it m 
the form of a globular tumor, resembling the uterus after delivery. 
Per vaginam it may generally be ascertained that the presenting part 
has suddenly receded, and can no longer be made out, or some other 
part of the foetus may be found in its place. If the rupture be exten- 
sive, it may be appreciable on vaginal examination, and, sometimes, 
a loop of intestine may be found protruding through the tear. Other 
occasional signs have been recorded, such as an emphysematous state 
of the lower part of the abdomen, resulting from the entrance of air 
into the cellular tissue ; or the formation of a sanguineous tumor in 
the hypogastrium or vagina. These are too uncommon and too vague 
to be of much diagnostic value. 

Unfortunately, the symptoms are by no means always so distinct, 
and cases occur in which most of the reliable indications, such as the 
sudden cessation of the pains, the external hemorrhage, and the retro- 
cession of the presenting part, may be absent. In some cases, indeed, 



RUPTURE OF THE UTERUS. 457 

the symptoms have been so obscure that the real nature of the case has 
only been detected after death. It is rarely, however, that the occur- 
rence of shock and prostration is not sufficiently distinct to arouse 
suspicion, even in the absence of the usual marked signs. In not a 
few cases distinct and regular contractions have gone on after lacera- 
tion, and the child has even been born in the usual way. Of course, 
in such a case mistake is very possible. So curious a circumstance is 
difficult of explanation. The most probable way of accounting for it 
is, that the laceration has not implicated the fundus of the uterus, 
which contracted sufficiently energetically to expel the foetus. Hence 
it will be seen that the symptoms are occasionally obscure, and the 
practitioner must be careful not to overlook the occurrence of so 
serious an accident because of the absence of the usual and character- 
istic symptoms. 

Prognosis. — The prognosis is necessarily of the gravest possible 
character, but modern views as to treatment perhaps justify us in say- 
ing that it is not so absolutely hopeless as has been generally taught 
in our obstetric works. When we reflect on what has occurred — the 
profound nervous shock ; the profuse hemorrhage, both external and, 
especially, into the peritoneal cavity, where the blood coagulates and 
forms a foreign body ; the passage of the uterine contents into the 
abdomen, with the inevitable result of inflammation and its conse- 
quences, if the patient survive the primary shock — the enormous 
fatality need cause no surprise. Jolly has found that out of 580 cases 
100 recovered — that is, in the proportion of 1 out of 6. This is a far 
more favorable result than we are generally led to anticipate ; and as 
many of the recoveries happened in apparently the most desperate and 
unfavorable cases, we should learn the lesson that we need not abandon 
all hope, and should at least endeavor to rescue the patient from the 
terrible dangers to which she is exposed. 

As regards the child, the prognosis is almost necessarily fatal ; and, 
indeed, the cessation of the foetal heart-sounds has been pointed out by 
McClintock as a sign of rupture in doubtful cases. The shock, the 
profuse hemorrhage, and the time that must necessarily elapse before 
the delivery of the child, are of themselves quite sufficient to explain 
the fact that the foetus is almost always dead. 

Treatment, — From what has been said of the impossibility of fore- 
telling the occurrence of rupture, it must follow that no reliable 
prophylactic treatment can be adopted beyond that which is a matter 
of general obstetric principle, viz., timely interference when the uterine 
contractions seem incapable of overcoming an obstacle to delivery, 
either on the part of the pelvis or foetus. 

After rupture the main indications are to effect the removal of the 
child and the placenta, to rally the patient from the effects of the 
shock, and, if she survive so long, to combat the subsequent inflamma- 
tion and its consequences. By far the most important point to decide 
is the best means to be adopted for the removal of the child ; for it is 
admitted by all that the hopeless expectancy that was recommended 
by the older accoucheurs, or, in other words, allowing the patient to die 
without making any effort to save her, is quite inadmissible. If the 



458 LABOR. 

foetus be entirely within the uterine cavity, no doubt the proper course 
to pursue is to deliver at once per vias naturales, either by turning, by 
forceps, or by cephalotripsy. If any part other than the head present, 
turning will be best, great care being taken to avoid further increase 
of the laceration. If the head be in the cavity or at the brim of the 
pelvis, and within easy reach of the forceps, it may be cautiously 
applied, the child being steadied by abdominal pressure so as to 
facilitate its application. If there be, as is often the case, some slight 
amount of pelvic contraction, it may be preferable to perforate and 
apply the cephalotribe, so as to avoid any forcible attempts at extrac- 
tion, which might unduly exhaust the already prostrate patient and 
turn the scale against her. This will be the more allowable, since the 
child is, as we have seen, almost always dead, and we might readily 
ascertain if it be so by auscultation. 

After delivery extreme care must be taken in removing the placenta, 
and for this it will be necessary to introduce the hand. The placenta 
will generally be in the uterus, for if the rent be not large enough for 
the child to pass through, it may be inferred that the placenta will not 
have done so either. If it has escaped from the uterus, very gentle 
traction on the cord may bring it within reach of the hand, and so the 
passage of the hand through the tear to search for it will be avoided ; 
but, in all cases of this kind, there must have been a very considerable 
escape of blood into the uterine cavity, and abdominal section will 
probably give the patient a better chance of recovery. 

There can be but little doubt that, in the cases indicated, such is the 
proper treatment, and that which affords the mother the best chance. 
Unfortunately, the cases in which the child remains entirely in utero 
are comparatively uncommon, and generally it will have escaped into 
the abdomen, along with much extravasated blood. The usual plan 
of treatment recommended under such circumstances is to pass the 
hand through the fissure (some have even recommended that it should 
be enlarged by incision if necessary), to seize the feet of the foetus, to 
drag it back through the torn uterus, and then to reintroduce the hand 
to search for and remove the placenta. Imagine what occurs during 
the process. The hand gropes blindly among the abdominal viscera, 
the forcible dragging back of the foetus necessarily tears the uterus 
more and more, and, above all, the extravasated blood remains as a 
foreign body in the peritoneal cavity, and necessarily gives rise to the 
most serious consequences. It is surely hardly a matter of surprise 
that there is scarcely a single case on record of recovery after this 
procedure. 

Of late years a strong feeling has existed that, whenever the child 
has entirely, or in great part escaped into the abdominal cavity, the 
operation of laparotomy affords the mother a far better chance of 
recovery ; and it has now been performed in many cases with the most 
encouraging results. It is easy to see why the prospects of success 
are greater. The uterus being already torn, and the peritoneum 
opened, the only additional danger is the incision of the abdominal 
parietes, which gives us the opportunity of washing out the peritoneal 
cavitv and of removing all the extravasated blood, the retention of 



RUPTURE OF THE UTE.RUS. 



459 



which so seriously adds to the dangers of the case, as well as closing the 
rents in the uterus, if it be within reach, with both deep and superficial 
sutures, as in the improved Csesarean section. Another advantage is 
that, if the patient be excessively prostrate, the operation may be 
delayed until she has somewhat rallied from the effects of the shock, 
whereas delivery by the feet is generally resorted to as soon as the 
rupture is recognized, and when the patient is in the worst possible 
condition for interference of any kind. 

Jolly has carefully tabulated the results of the various methods of 
treatment, and, making every allowance for the unavoidable errors of 
statistics, it seems beyond all question that the results of laparotomy 
are so greatly superior to those of other plans that I think its adoption 
may be fairly laid down as a rule whenever the foetus is no longer 
wholly within the uterine cavity. 

Comparative Eesults of Various Methods of Treatment after 
Rupture of Uterus. 



Treatment. 


No. of cases. 


Expectation 

Extraction per vias naturales . 
Laparotomy 


144 

3S2 

38 



Deaths. 

142 

310 

12 



Recoveries. 



Per cent, or 
recoveries. 



1.4 

19 
68. 4 



Of course, this table will not justify the conclusion that 68 per cent, 
of the cases of ruptured uterus in which laparotomy is performed will 
recover; but it may fairly be taken as proving that the chances of 
recovery are at least three or four times as great as when the more 
usual practice is adopted. 1 

It is perhaps needless to say that the operation must be performed 
with the same minute care that has raised ovariotomy to its present 
pitch of perfection, and that especial attention should be paid to the 
washing out of the peritoneum, the removal of foreign matters, and to 
the careful suturing of the uterine wound, whenever that is practicable. 

Porro's Operation has been suggested instead of simple laparotomy. 
In seven cases tabulated by Godson, in which this operation was per- 
formed afier rupture of the uterus, the mothers all died f but this does 
not prove that this plan, which adds little to the daugers of the case, 
should not be adopted. It has, at least, the advantage of effectually 
preventing the possibility of the recurrence of rupture in a future 
pregnancy. 

Lacerations of the cervix are of very common occurrence. Occa- 
sionally, after delivery, they may cause hemorrhage, when the uterus 



1 American Puerperal Laparotomies.— After a search of several years. I have thus far collected 
forty cases in the United States, with twenty-one women and two children saved. One mother 
and child werasaved by an immediate operation with a pocket-knife, in 1869. I presume that a 
general record of American operations published and unpublished would show a saving of about 
50 per cent., which is much lower than that claimed by Trask and Jolly, collected from published 
reports, and less than I thought myself a year ago Take Trask's foreign cases, twenty, .nd our 
own forty, and we have native and foreign, sixty, with thirty-seven recoveries and twenty-three 
deaths. I look upou our own statistics as much "more reliable, because many of the unpublished 
cases were searched out by correspondence— Harris's note to the third American edition. 

2 A successful case has recently been reported by Professor Slayjausky, of St. Petersburg. 



460 LABOR. 

itself is firmly contracted ; or secondary hemorrhage during the puer- 
peral month. As a rule they are not recognized, and it is only of late 
years, and chiefly owing to the labors of Emmet, that their important 
influence in producing various chronic forms of uterine disease has 
been realized. In the large majority of cases the lacerations are lateral, 
either on one or both sides of the cervix. If they give rise to 
hemorrhage, the local application of styptics is probably the best re- 
source. Whether it is advisable to treat severe forms by the imme- 
diate application of silver sutures, as recommended by Pallen, 1 is a 
subject as yet too little understood to justify the expression of an 
opinion. 

Recapitulation — To recapitulate, I think what has been said 
justifies the following rules of treatment after rupture : 

1. If the head or presenting part be above the brim, and the foetus 
still in utero — forceps, turning, or cephalotripsy according to circum- 
stances. 

2. If the head be in the pelvic cavity — forceps or cephalotripsy. 

3. If the foetus have wholly, or in great part, escaped into the ab- 
dominal cavity — laparotomy. 

As to the subsequent treatment, little need be said, since in this we 
must be guided by general principles. The chief indication will be to 
remove shock, to rally the patient by stimulants, etc., and to combat 
secondary results by opiates and other appropriate remedies. 

Drainage has been recommended in cases in which laparotomy has 
not been resorted to, and the results are said to have been good. 
Mann 2 advises that a large piece of drainage-tube should be bent in 
the middle, at which point a free opening should be made. This bent 
portion is passed for about half an inch through the laceration, the 
free ends are fastened together beyond the vulva, and covered with an 
antiseptic dressing. After forty-eight hours the wound should be 
regularly irrigated with 2 per cent, solution of carbolic acid. 

Lacerations of the vagina occasionally take place, and in the 
great majority of cases they are produced by instruments, either from 
a want of care in their introduction, or from undue stretching of the 
vaginal walls during extraction with the forceps. Slight vaginal 
lacerations are probably much more common after forceps delivery 
than is generally believed to be the case. As a rule, they are produc- 
tive of no permanent injury, although it must not be forgotten that 
every breach of continuity increases the risk of subsequent septic 
absorption. When the laceration is sufficiently deep to tear through 
the recto- vaginal septum or the anterior vaginal wall, the passage of 
the urine or feces is apt to prevent its edges uniting ; then that most 
distressing condition, recto-vaginal or vesico-vaginal fistula, is estab- 
lished. 

it must not be supposed that fistula? are often the result of injury 
during operative interference. That is a common but very erroneous 
opinion both among the profession and the public. In the vast 
majority of cases the fistulous opening is the consequence of a slough 

1 Transactions of the International Medical Congress, vol- iv. 

2 Centralblatt f. Gyniikologie, Bd. v. S. 377. 



RUPTURE OF THE UTERUS. 461 

resulting from inflammation, produced by long-continued pressure of 
the vaginal Avails between the child's head and the bony pelvis, in 
cases in which the second stage has been allowed to go on too long. 
In most of these cases instruments were doubtless eventually used, 
and they get the blame of the accident ; whereas the fault lay, not in 
their being employed, but rather in their not having been used soon 
enough to prevent the contusion and inflammation which ended in 
sloughing. 

AYhen vesico-vagmal fistulas are the result of lacerations during 
labor, the urine must escape at once ; but this is rarely the case. In 
the large majority of cases the urine does not pass per vaginam until 
more than a week after delivery, showing that a lapse of time is neces- 
sary for inflammatory action to lead to sloughing. In order to throw 
some light on these points, on which very erroneous views have been 
held, I have carefully examined the histories, from various sources, of 
63 cases of vesico-vagmal fistula. 

Statistical Pacts. — 1st. In 20 no instruments were employed. Of 
these, there were in labor 

Under 24 hours 2 

From 24 to 48 " 8 1 

" 40 to 70 " 2 

" 70 to 80 " 7 

80 hours and upward 1 

20 

Therefore out of these 20 cases one-half were certainly more than 
forty-eight hours in labor, and 6 of the remaining 10 were probably 
so also. In only one of them is the urine stated to have escaped per 
vaginam immediately after delivery. In 7 it is said to have done so 
within a week, and in the remainder after the seventh day. 

2d. In 34 cases instruments were used, but there is no evidence of 
their having produced the accident. Of these there were in labor 

Under 24 hours 2 

From 24 to 48 " 8 

" 48 to 72 " 10 

" 72 hours and upward 14 

34 

The urine escaped within twenty-four hours in 2 cases only, within a 
week in 16, and after the seventh day in 15. 

So that here again we have the history of unduly protracted de- 
livery, 24 out of the 34 having been certainly more than forty-eight 
hours in labor. 

3d. In 9 cases the histories show that the production of the fistula 
may fairly be ascribed to the unskilled use of instruments. Of these 
there were in labor 

Under 24 hours 7 

From 21 to IS " 1 

" 48 to 72 " 1 



The urine escaped at once in 7 cases, and in the remaining 2 after the 
seventh day. 

1 But of these in 7 no precise time is stated. Six of them are marked very tedious, therefore they 
prohably exceeded the limit. 



462 LABOK. 

These statistics seem to me to prove, in the clearest manner, that, 
in the large majority of cases, this unhappy accident may be directly 
traced to the bad practice of allowing labor to drag on many hours in 
the second stage without assistance, and not to premature instrumental 
interference. This question has recently been elaborately studied by 
Emmet, who gives numerous statistical tables which fully corroborate 
these views. His conclusion, the result of much practical experience 
of vesico-vaginal fistula?, is worthy of being quoted : " I do not hesi- 
tate," he says, " to make the statement that I have never met with a 
case of vesico-vaginal fistula which, without doubt, could be shown to 
have resulted from instrumental delivery. On the contrary, the entire 
weight of evidence is conclusive in showing that the injury is a conse- 
quence of delay in delivery." 1 

Treatment. — As to the treatment of vaginal laceration, little can be 
said. In the slighter cases antiseptic vaginal injections will be useful 
to lessen the risk of septic absorption ; and the graver, when vesico- 
vaginal or recto-vaginal fistulas have actually formed, are not within 
the domain of the obstetrician, but must be treated surgically at some 
future date. 



CHAPTER XVII. 

INVEESION OF THE UTERUS. 

Inversion of the uterus shortly after the birth of the child is one 
of the most formidable accidents of parturition, leading to symptoms 
of the greatest urgency, not rarely proving fatal, and requiring prompt 
and skilful treatment. Hence it has obtained an unusual amount of 
attention, and there are few obstetric subjects which have been more 
carefully studied. 

Fortunately, the accident is of great rarity. It was only observed 
once in upward of 190,800 deliveries at the Rotunda Hospital since 
its foundation in 1745, and not once in 250,000 deliveries in the 
Vienna Lying-in Hospital ; and many practitioners have conducted 
large midwifery practices for a lifetime without ever having witnessed 
a case. It is none the less needful, however, that we should be thor- 
oughly acquainted with its natural history, and with the best means 
of dealing with the emergency when it arises. 

Acute and Chronic Forms. — Inversion of the uterus may be met 
with in the acute or chronic form ; that is to say, it may come under 
observation either immediately or shortly after its occurrence, or not 
until after a considerable lapse of time, when the involution follow- 
ing pregnancy has been completed. The latter falls more properly 

1 The Principles and Practice of Gynecology, p. 669. 



INVERSION OF THE UTERUS, 



463 



Fig. 154. 




under the province of the gynecologist, and involves the consideration 
of many points that would be out of place in a work on obstetrics. 
Here, therefore, the acute form alone is considered. 

Description. — Inversion consists essentially in the enlarged and 
empty uterus being turned inside out, either partially or entirely; and 
this may occur in various degrees, three 
of which are usually described, and are 
practically useful to bear in mind. In the 
first and slightest degree there is merely 
a cup-shaped depression of the fundus 
(Fig. 154) ; in the second the depression 
is greater, so that the inverted portion 
forms an introsusception, as it were, and 
projects downward through the os in the 
form of a round ball, not unlike the body 
of a polypus, for which, indeed, a care- 
less observer might mistake it ; and, 
thirdly, there is the complete variety, in 
which the whole organ is turned inside 
out and may even project beyond the 
vulva. 

The symptoms are generally very 
characteristic, although, when the amount 
of inversion is small, they may entirely 
escape observation. They are chiefly those 
of profound nervous shock, viz., fainting, 
small, rapid, and feeble pulse, possibly 
convulsions and vomiting, and a cold, 
clammy skin. Occasionally severe abdominal pain and bearing down 
are felt. Hemorrhage is a frequent accompaniment, sometimes to a 
very alarming extent, especially if the placenta be partially or entirely 
detached. The loss of blood depends to a great extent on the condi- 
tion of the uterine parietes. If there be much contraction on the part 
that is not inverted, the introsuscepted part may be sufficiently com- 
pressed to prevent any great loss. If the entire organ be in a state of 
relaxation the loss may be excessive. 

The occurrence of such symptoms shortly after delivery would of 
necessity lead to an accurate examination, when the nature of the case 
may be at once ascertained. On passing the finger into the vagina we 
either find the entire uterus forming a globular mass — to which the 
placenta is often attached — or, if the inversion be incomplete, the 
vagina is occupied by a firm, round, and tender swelling, which can 
be traced upward through the os uteri. The hand placed on the 
abdomen will detect the absence of the round ball of the contracted 
uterus; the bimanual examination may even enable us to feel the cup- 
shaped depression at the site of inversion. 

Differential Diagnosis. — When such signs are observed immedi- 
ately after delivery mistake is hardly possible. Numerous instances, 
however, are recorded in which the existence of inversion was not 
immediately detected, and the tumor formed by it only observed after 



Partial inversion of the fundus. 
(From a preparation in the Museum 
of Guy's Hospital.) 



464 LABOR. 

the lapse of several days, or even longer, when the general symptoms 
led to vaginal examination. It is probable that, in such cases, a 
partial inversion had taken place shortly after delivery, which, as time 
elapsed, became gradually converted into the more complete variety. 
In a case of this kind, as in a chronic inversion, some care is necessary 
to distinguish the inversion from a uterine polypus, which it closely 
resembles. The cautious insertion of the sound will render the diag- 
nosis certain, since its passage is soon arrested in inversion ; while, if 
the tumor be polypoid, it readily passes in as far as the fundus. 

The mechanism by "which inversion is produced is well worthy 
of study, and has given rise to much difference of opinion. 

A very general theory is that it is caused, in many cases, by mis- 
management of the third stage of labor, either by traction on the cord, 
the placenta being still adherent, or by improperly applied pressure on 
the fundus ; the result of both these errors being a cup-shaped depres- 
sion of the fundus, which is subsequently converted into a more com- 
plete variety of inversion. That such causes may suffice to start the 
inversion cannot be doubted, but it is probable that their frequency 
has been much exaggerated. Still, there are numerous recorded cases 
in which the commencement of the inversion can be traced to them. 
Improperly applied pressure (as when the whole body of the uterus is 
not grasped in the hollow of the hand, but when a monthly nurse, or 
other uninstructed person, presses on the lower part of the abdomen, 
so as simply to push down the uterus en masse) is often mentioned in 
histories of the accident. Thus, in the Edinburgh Medical Journal for 
June, 1848, a case is related in which the patient would not have a 
medical man, but was attended by a midwife, who, after the birth of 
the child, pulled on the cord, while the patient herself clasped her 
hands and pushed down her abdomen, at the same time straining 
forcibly, when the uterus became inverted and the patient died of 
hemorrhage before assistance could be procured. Here both of the 
mechanical causes alluded to were in operation. In several cases it is 
mentioned that the accident occurred while the nurse was compressing 
the abdomen. That the accident is practically impossible when firm 
and equable contraction has taken place cannot be questioned. Hence 
it is of paramount importance that the practitioner should himself 
carefully attend to the conduct of the third stage of labor. 

In a large proportion of cases no mechanical causes can be traced, 
and the occurrence of spontaneous inversion must be admitted. There 
are various theories held as to how this occurs. Partial and irregular 
contraction of the uterus is generally admitted to be an important 
factor in its production ; but it is still a matter of dispute whether the 
inversion is produced mainly by an active contraction of the fundus 
and body of the uterus, the lower portion and cervix being in a state 
of relaxation ; or whether the precise reverse of this exists, the fundus 
being relaxed and in a state of quasi-paralysis, while the cervix and 
lower portion of the uterus are regularly contracted. The former is 
the view maintained by Radford and Tyler Smith, while the latter is 
upheld by Matthews Duncan. 

There are good clinical reasons for believing that Duncan's view 



INVERSION OF THE UTERUS. 



465 



more nearly corresponds with the true facts of the case ; for, if the 
fundus and body of the uterus be really in a state of active contraction, 
while the cervix is relaxed, we have, as Duncan points out, the very 
condition which is normal and desirable after delivery, and that Avhich 
we do our best to produce. If, however, the opposite condition exists, 
and the fundus be relaxed, while the lower portion is spasmodically 
contracted, a state exists closely allied to the so-called hour-glass con- 
traction. Supposing now any cause produces a partial depression of 
the fundus, it is easy to understand how it may be grasped by the 
contracted portion, and carried more and more down, in the manner 
of an introsusception, until complete inversion results. That such 
partial paralysis of the uterine walls often exists, especially about the 
placental site, was long ago pointed out by Rokitansky and other 
pathologists. This theory supposes the original partial depression and 
relaxation of the fundus. How this is ofteu produced by mismanage- 
ment of the third stage has already been pointed out; but even in the 
absence of such causes, it may result from strong bearing-down efforts 
on the part of the patient ; or, as Duncan holds, from the absence of 
the retentive power of the abdomen. Indeed, the incompatibility of 
an actively contracted state of the fundus with the partial depression 
which is essential, according to both views, for the production of inver- 
sion, is the strongest argument in favor of Duncan's theory. 

A totally different view has more recently been sustained by Dr. 
Taylor, of New York, who maintains that " spontaneous active in- 
version of the uterus rests upon prolonged natural and energetic action 
of the body and fundus; the cervix, the lower part, yielding first, is 
thus rolled out, or everted or doubled up, as there is no obstruction 
from the contractility of the cervix, which is at rest or functionally 
paralyzed ; the body is gradually, some- 
times instantaneously, forced lower and 
lower, or inverted." 1 That partial inversion 
may commence at the cervix was pointed 
out by Duncan in his paper, who depicts it 
in the accompanying diagram (Fig. 155), 
and states it to be of not unfiequent occur- 
rence. It is not impossible that occasionally 
such a state of things should be carried on 
to complete inversion. But there are serious 
objections to the acceptance of Dr. Taylor's 
view that such is the principal cause of in- 
version, since the process above described 
would be of necessity a slow and long-con- 
tinued one, whereas nothing is more certain 
than that inversion is generally sudden and 
accompanied by acute symptoms of shock, 
and is often attended by severe hemorrhage, 
which could not occur when such excessive 
contraction was taking place. 

The treatment of inversion consists in 



Fig. 155. 




Illustrating the commencement 
of inversion at the cervix. (Alter 
Duncan ) 



New York Med. Journ., vol. xv. p. 449. 
30 



■166 LABOR. 

restoring the organ to its natural condition as soon as possible. Every 
moment's delay only serves to render restoration more difficult, as the 
inverted portion becomes swollen and strangulated; whereas if the 
attempt at reposition be made immediately, there is generally compara- 
tively little difficulty in effecting it. Therefore, it is of the utmost 
importance that no time should be lost, and that we should not over- 
look a partial or incomplete inversion. Hence the occurrence of any 
uu usual shock, pain, or hemorrhage after delivery, without any readily 
ascertained cause, should always lead to a careful vaginal examination. 
A want of attention to this rule has too often resulted in the existence 
of partial inversion being overlooked until its reduction was found to 
be difficult or impossible. 

In attempting to reduce a recent inversion, the inverted portion of 
the uterus should be grasped in the hollow of the hand and pushed 
gently and firmly upward into its natural position, great care being 
taken to apply the pressure in the proper axis of the pelvis, and. to use 
counter-pressure, by the left hand, on the abdominal walls. Barnes 
lays stress on the importance of directing the pressure toward one side 
so as to avoid the promontory of the sacrum. The common plan of 
endeavoring to push back the fundus first has been well shown by 
McClintock 1 to have the disadvantage of increasing the bulk of the 
mass that has to be reduced, and he advises that, while the fundus is 
lessened in size by compression, we should, at the same time, endeavor 
to push up first the part that was less inverted — that is to say, the por- 
tion nearest the os uteri. Should this be found impossible, some assist- 
ance may be derived from the manoeuvre, recommended by Merrimau 
and others, of first endeavoring to push up one side or wall of the 
uterus, and then the other, alternating the upward pressure from one 
side to the other as we advance. It> often happens, as the hand is thus 
applied, that the uterus somewhat suddenly replaces itself, sometimes 
with an audible noise, much as an India-rubber bottle would do under 
similar circumstances. When reposition has taken place, the hand 
should be kept for some time in the uterine cavity to excite tonic con- 
traction ; or a stream of hot water at 110° F. may be injected, and if 
that fails, a weak solution of perchloride of iron, so as to cause tonic 
contraction of the uterus and thus prevent a recurrence of the accident. 

It is hardly necessary to point out how much these manoeuvres will 
be facilitated by placing the patient fully under the influence of an 
anaesthetic. 

There has been much difference of opinion as to the management of 
the placenta in cases in which it is still attached when inversion occurs. 
Should we remove it before attempting reposition, or should we first 
endeavor to rein vert the organ and subsequently remove the placenta? 
The removal of the placenta certainly much diminishes the bulk of 
the inverted portion, and, therefore, renders reposition easier. On the 
other hand, if there be much hemorrhage, as is so frequently the case, 
the removal of the placenta may materially increase the loss of blood. 
For this reason most authorities recommend that an endeavor should 

1 Diseases of Women , p. 79. 



INVERSION - OF THE UTERUS. 467 

be made at a reduction before peeling otf the after-birth. But if any 
delay or difficulty be experienced from the increased bulk, no time 
should be lost, and it is in every way better to remove the placenta 
and endeavor to reinvert the organ as soon as possible. 

Supposing we met with a case in which the existence of inversion 
has been overlooked for days, or even for a week or two, the same 
procedure must be adopted ; but the difficulties are much greater, and 
the longer the delay the greater they are likely to be. Even now r , 
however, a well-conducted attempt at taxis is likely to succeed. Should 
it fail, we must endeavor to overcome the difficulty by continuous 
pressure applied by means of caoutchouc bags distended with water 
and left in the vagina. It is rarely that this will fail in a compara- 
tively recent case, and such only are now under consideration. It is 
likely that by pressure applied in this Avay for twenty- four or forty- 
eight hours, and then followed by taxis, any case detected before the 
involution of the uterus is completed may be successfully treated. 



PART IV. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 

INDUCTION OF PREMATURE LABOR. 

History of the Operation. — The first of the obstetric operations 
we have to consider is the induction of premature labor, an operation 
which, like the use of forceps, was first suggested and practised in 
England, and the recognition of which, as a legitimate procedure, we 
also chiefly owe to the labor of English obstetricians, in spite of 
much opposition both at home and abroad. It is not known with cer- 
tainty to whom we owe the original suggestion, but we are told by 
Denman that in the year 1756 there was a consultation of the most 
eminent physicians at that time in London, to consider the advantages 
which might be expected from the operation. The proposal met with 
formal approval, and was shortly after carried into practice by Dr. 
Macaulay, the patient being the wife of a linendraper in the Strand. 
From that time it has flourished in Great Britain, the sphere of its 
application has been largely increased, and it has been the means of 
saving many mothers and children who would otherwise, in all prob- 
ability, have perished. On the Continent it was long before the opera- 
tion was sanctioned or practised. Although recommended by some of 
the most eminent German practitioners, it was not actually performed 
until the year 1804. In France the opposition was long-continued 
and bitter. Many of the leading teachers strongly denounced it, and 
the Academy of Medicine formally discountenanced it so late as the 
year 1827. The objections were chiefly based on religious grounds, 
but partly, no doubt, on. mistaken notions as to the object proposed to 
be gained. Although frequently discussed, the operation was never 
actually carried into practice until the year 1831, when Stoltz per- 
formed it with success. Since that time opposition has greatly ceased, 
and it is now employed and highly recommended by the most distin- 
guished obstetricians of the French schools. 

Objects of the Operation. — In inducing premature labor, we pro- 
pose to avoid or lessen the risk to which, in certain cases, the mother 
is exposed by delivery at term, or to save the life of the child which 
might otherwise be endangered. Hence the operation may be indi- 
cated either on account of the mother alone, or of the child alone, or, 
as not unfrequently happens, of both together. 
(468) 



INDUCTION OF PREMATURE LABOR. 469 

In by far the largest number of cases the operation is performed on 
account of defective proportion between the child aud the maternal 
passages, due to some abnormal condition on the part of the mother. 
This want of proportion may depend on the presence of tumors either 
of the uterus or growing from the pelvis. But most frequently it 
arises from deformity of the pelvis (p. 417), and it is needless to repeat 
what has been said on that point. I shall therefore only briefly refer 
to a few more uncommon causes which occasionally necessitate its 
performance. 

One of these is an habitually large, or over-firmly ossified, foetal 
head. Should we meet with a case in which the labors are always 
extremely difficult, and the head apparently of unusual size, although 
there is no apparent want of space in the pelvis, the induction of labor 
would be perfectly justifiable, and in all probability would accomplish 
the desired object. In such cases the full period of delivery would 
require to be anticipated by a very short time. A week or a fortnight 
might make all the difference between a labor of extreme severity and 
one of comparative ease. 

There is a large class of cases in which the condition of the mother 
indicates the operation. Many of these have already been considered 
when treating of the diseases of pregnancy. Amongst them may be 
mentioned vomiting which has resisted all treatment, and which has 
produced a state of exhaustion threatening to prove fatal ; chorea, 
albuminuria, convulsions, or mania; excessive anasarca, ascites, or 
dyspnoea connected with disease of the heart, lungs, or liver, which 
may be, in a great measure, caused by the pressure of the enlarged 
uterus ; in fact, any condition or disease affecting the mother, provided 
only Ave are convinced that the termination of pregnancy would give 
the patient relief, and that its continuance would involve serious 
danger. It need hardly be pointed out that the induction of labor 
for any such causes involves great responsibility, and is decidedly 
open to abuse ; no practitioner would, therefore, be justified in resort- 
ing to it — especially if the child has not reached a viable age — 
without the most anxious consideration. Xo general rules can be laid 
down. Each case must be treated on its own merits. It is obvious 
that the nearer the patient is to the full period, the greater will be the 
chance of the child surviving, and the less hesitation need then be felt 
in consulting the interest of the mother. 

In another class of cases the operation is indicated by circumstances 
affecting the life of the child alone. Of these the most common are 
those in which the child dies, in several successive pregnancies, before 
the termination of utero-gestation. This is generally the result of 
fatty, calcareous, or syphilitic degeneration of the placenta, which is 
thus rendered incapable of performing its functions. These changes 
in the placenta seldom commence until a comparatively advanced 
period of pregnancy ; so that if labor be somewhat hastened Ave may 
hope to enable the patient to give birth to a living and healthy child. 
The experience of the mother will indicate the period at which the 
death of the foetus has formerly taken place, as she would then have 
appreciated a difference in her sensations, a diminution in the vigor of 



470 OBSTETRIC OPERATIONS. 

the foetal movements, a sense of weight and coldness, and similar 
signs. For some weeks before the time at which this change has been 
experienced, we should carefully auscultate the foetal heart from day 
to day, and in most cases the approach of danger will be indicated 
sufficiently soon to enable us to interfere with success, by tumultuous 
and irregular pulsations, or a failure in their strength and frequency. 
On the detection of these, or on the mother feeling that the move- 
ments of the child are becoming less strong, the operation should at 
once be performed. Simpson also induced premature labor with suc- 
cess in a patient who had twice given birth to hydrocephalic children. 
In the third pregnancy, which he terminated before the natural period, 
the child was well formed and healthy. 

Some obstetricians have proposed to induce labor, with the view of 
saving the child, when the mother was suifering from mortal disease. 
This indication is however, so extremely doubtful, from a moral point 
of view, that it can hardly be considered as ever justifiable. 

Various Methods of Inducing Labor. — The means adopted for 
the induction of labor are very numerous. Some of them act through 
the maternal circulation, as the administration of ergot and other 
oxytocics ; others by their power of exciting reflex action, or by in- 
terfering with the integrity of the ovum, or by a combination of 
both, as the vaginal douche, separation of the membranes from the 
uterine walls, puncture of the ovum, dilatation of the os, stimulating 
enemata, or irritation of the breasts. The former class are never 
employed in modern obstetric practice. Of the latter, some offer 
special advantages in particular cases, but none are equally adapted 
for all emergencies. Often a combination of more methods than one 
will be found most useful. I shall mention the various methods in 
use, and discuss briefly the relative advantages and disadvantages of 
each. 

Puncture of Membranes. — The evacuation of the liquor amnii by 
the puncture of the membranes was the first method practised, and 
was that recommended by Denman and all the earlier writers. It is 
the most certain which can be employed, as it never fails, sooner or 
later, to induce uterine contractions. There are, however, several dis- 
advantages connected with it which are sufficient to contra-indicate its 
use in the majority of cases. It is uncertain as regards the time taken 
in producing the desired effect, pains sometimes coming on within a 
few hours, but occasionally not until several days have elapsed. The 
contracting walls of the uterus press directly on the body of the child, 
which, being frail and immature, is less able to bear the pressure than 
at the full period of pregnancy. Hence it involves great risk to the 
foetus. Besides, the escape of the water does away with the fluid 
wedge so useful in dilating the os, and should version be necessary 
from malpresentation — a complication more likely to occur than in 
natural labor — the operation would have to be performed under very 
unfavorable conditions. These objections are sufficient to justify the 
ordinary opinion that this procedure should not be adopted unless 
other means have been tried and failed. Every now and then cases 
are met with in which it is extremly difficult to arouse the uterus to 



INDUCTION OF PREMATURE LABOR. 471 

action, and under such circumstances, in spite of its drawbacks, this 
method will be found to be very valuable. When the operation has 
to be performed before the child is viable — that is, before the seventh 
month — these objections do not hold, and then it is the simplest and 
readiest procedure we can adopt. Indeed, in producing early abortion, 
no other is practicable. The operation itself is most simple, requiring 
only a quill, stiletted catheter, or other suitable instrument, to be 
passed up to the os, carefully guarded by the fingers of the left hand 
previously introduced, and to be pressed against the membranes until 
perforation is accomplished. Meissner, of Leipzig, has proposed as a 
modification of this plan, that the membrane should be punctured 
obliquely, three or four inches above the os, so as to admit of a gradual 
and partial escape of the amniotic fluid, thus lessening the risk to the 
child from pressure by the uterus. For this purpose he employed a 
curved silver canula containing a small trocar, which can be pro- 
jected after introduction. The risk of injuring the uterus by such an 
instrument would be considerable, and we have other and better means 
at our command which render it unnecessary. When we require to 
produce early abortion, it would be well not to attempt to puncture 
the membranes with a sharp-pointed instrument. The object can be 
effected with certainty and greater safety by passing an ordinary 
uterine sound through the os and turning it around once or twice. 

Administration of Oxytocics. — The administration of ergot of 
rye, either alone or combined with borax and cinnamon, has been 
sometimes resorted to. This practice has been principally advocated 
by Rainsbotham, who was in the habit of exhibitiug scruple doses of 
the powdered ergot every fourth hour until delivery took place. 
Sometimes he found that as many as thirty or forty doses were re- 
quired to effect the object ; occasionally labor commenced after a single 
dose. Finding that the infantile mortality was very great when this 
method was followed, he modified it and administered two or three 
doses only, and, if these proved insufficient, he punctured the mem- 
branes. There can be no doubt that ergot possesses the power of in- 
ducing uterine contractions. The risk to the child is, however, quite 
as great as when the membranes are punctured ; for not only is it 
subject to injurious pressure from the tumultuous and irregular con- 
tractions which the ergot produces, but the drug itself, when given in 
large doses, seems to exert a poisonous influence on the foetus. For 
these reasons ergot may properly be excluded from the available 
means of inducing labor. 

Methods Acting* Indirectly on the Uterus. — Various methods 
have been recommended which act indirectly on the uterus, the source 
of irritation being at a distance. Thus D'Outrepont used frequently 
repeated abdominal frictions and tight bandages. Scanzoui, remem- 
bering the intimate connection l)etween the mammae and uterus, and 
the tendency which irritation of the former has to induce contraction 
of the latter, recommended the frequent application of cupping-glasses 
to the breasts. Radford and others have employed galvanism. 
Stimulating enemata have been employed. All these methods have 
occasionally proved successful, and, unlike the former plans we have 



472 OBSTETRIC OPERATIONS. 

mentioned, they are not attended by any special risk to the child. 
They are, however, much too uncertain to be relied on, besides being 
irksome both to the patient and practitioner. 

The artificial dilatation of the os uteri in imitation of its natural 
opening in labor was first practised by Kluge. He was in the habit 
of passing within the os a tent made of compressed sponge, and allow- 
ing it to dilate by imbibition of fluid. If labor was not provoked 
within twenty-four hours he removed it and introduced one of larger 
dimensions, changing it as often as was necessary until his object was 
accomplished. Although this operation seldom failed to induce labor, 
it had the disadvantage of occupying an indefinite time, and the irrita- 
tion produced was often painful and annoying. Dr. Keiller, of Edin- 
burgh, was the first to suggest caoutchouc bags, distended by air, as a 
means of dilating the os. This plan has been perfected by Dr. Robert 
Barnes in his well-known dilators, which are of great use in many 
cases in which artificial dilatation of the cervix is necessary. They 
consist of a series of India-rubber bags of various sizes with a tube 
attached (Fig. 156), through which water can be injected by an ordinary 
Higginson's syringe. They have a small pouch fixed externally, in 
which a sound can be placed, so as to facilitate their 
Fiq ; 156 , introduction. When distended with water the bags 

assume somewhat of a fiddle shape, bulging at both 
extremities, which insures their being retained within 
the os. When first introduced into practice as a 
means of inducing labor, it was thought that this 
method gave a complete control over the process, so 
that it could be concluded within a definite time at 
the will of the operator. The experience of those 
who have used it much has certainly not justified 
this anticipation. It is true that occasionally con- 
tractions supervene within a few hours after dilata- 
tion has been commenced ; but, on the other hand, 
the uterus often responds very imperfectly to this 
kind of stimulus, and the bags may be inserted for 
many consecutive hours without the desired result 

Barnes' bag for dilat- • ■ 1 pi i 1 • 

ing the cervix. supervening, the puncture 01 the membranes being 
eventually necessary in order to hasten the process. 
Indeed, my own experience would lead me to the conclusion that, as a 
means of evoking uterine contraction, cervical dilatation is very un- 
satisfactory. Dr. Barnes himself has evidently seen reason to modify 
his original views, for while he at first talked of the bags as enabling 
us to induce labor with certainty at a given time, he has since recom- 
mended that uterine action should be first provoked by other means, 
the dilators being subsequently used to accelerate the labor thus 
brought on. The bags thus employed find, as I believe, their most 
useful and a very valuable application ; but when used in this way 
they cannot be considered a means of originating uterine action. A 
subsidiary objection to the bags is the risk of displacing the presenting 
part I have, for example, introduced them when the head was pre- 
senting, and, on their removal, found the shoulder lying over the os. 




INDUCTION OF PREMATURE LABOR, 



473 



It is not difficult to understand how the continuous pressure of a dis- 
tended bag in the internal os might easily push away the head, which 
is so readily movable so long as the membranes are unruptured. Still, 
if labor be in progress, and the os insufficiently dilated, the possibility 
of this occurrence is not a sufficient reason for not availing ourselves 
of the undoubtedly valuable assistance which the dilators are capable 



Fig. 157. 







Champetier de Ribes' dilator and introducing forceps. 

of giving. A modified form of dilator, invented by Champetier de 
Ribes, has been highly spoken of and promises to be useful (Fig. 157). 
It differs from Barnes's instrument in being conical, in being made of 
inelastic waterproof silk, holding about seventeen ounces, and not 
capable of further distention, and in being much larger, so that when 
the expanded bag has passed through the cervical canal, the child can 
be quickly delivered. It is introduced by special forceps, and left until 
it is excelled by the pains. The average time in which this happened 



474 OBSTETRIC OPERATIONS. 

in sixteen cases was eight hours. It is rather more bulky than Barnes' 
dilators, aud from its size cannot be used unless there is some little 
dilatation of the os. 

Separation of the Membranes. — Some processes for inducing 
labor act directly on the ovum by separating the membranes, to a 
greater or less extent, from the uterine walls. The first procedure of 
the kind was recommended by Dr. Hamilton, of Edinburgh, and con- 
sisted in the gradual separation of the membranes for one or two 
inches all round the lower segment of the uterus. To reach them the 
finger had to be gently insinuated into the interior of the os, which 
was gradually dilated to a sufficient extent by a series of successive 
operations, repeated at intervals of three or four hours. When this 
had been accomplished, the forefinger was inserted and swept round 
between the membranes and the uterus, but it was frequently found 
necessary to introduce the greater part of the hand to effect the object 
and sometimes even this was not sufficient and a female catheter or 
other instrument had to be used for the purpose. The method w r as 
generally successful in bringing on labor, but it now and then failed, 
even in Dr. Hamilton's hands. It is certainly based on correct prin- 
ciples, but it is tedious and painful, both to the practitioner and the 
patient, and very uncertain in its time of action. For these reasons 
it has never been much practised. 

Vaginal and Uterine Douches. — In the year 1836, Kiwisch sug- 
gested a plan which, from its simplicity, has met with much approval. 
It consists in projecting, at intervals, a stream of warm or cold water 
against the os uteri. Its .action is doubtless complex. Kiwisch him- 
self believed that relaxation of the soft parts, through the imbibition 
of water, was the determining cause of labor. Simpson found that 
the method failed unless the water mechanically separated the mem- 
branes from the uterine walls. Besides this effect it probably directly 
induces reflex action by distending the vagina and dilating the os. In 
using it, it has been customary to administer a douche twice daily, 
and more frequently if rapid effects be desired. The number required 
varies in different cases. The largest number Kiwisch found it neces- 
sary to use was seventeen, the smallest five. The average time that 
elapses before labor sets in is four days. Hence the method is obvi- 
ously useless when rapid delivery is required. 

Dr. Cohen, of Hamburg, introduced an important modification of 
the process, which has been considerably practised. It consists in 
passing a silver or gum-elastic catheter some inches within the os, 
between the membranes and the uterine walls, and injecting the fluid 
through it directly into the cavity of the uterus. He used creasote 
or tar water, and injected without stopping until the patient com- 
plained of a feeling of distention. Others have found the plan 
equally efficacious when they only employed a small quantity of plain 
water, such as seven or eight ounces. Professor Lazarewitch, of 
Charkoff, is a strong advocate of this method. He believes that 
uterine action is evoked much more rapidly and certainly if the water 
be injected near the fundus, and he has contrived an instrument for 
the purpose, with a long metallic nozzle. 



INDUCTION" OF PREMATURE LABOR. 475 

Dangers of these Plans. — So many fatal cases have followed these 
methods, that it cannot be doubted that, in spite of their certainty and 
simplicity, there is an element of risk in them that should not be 
overlooked. Many of these are recorded in Barnes's work, and he 
comes to the conclusion, which the facts unquestionably justify, that 
" the douche, whether vaginal or intra-uterine, ought to be absolutely 
condemned as a means of inducing labor/' The precise reason of the 
danger is not very obvious. Sudden stretching of the uterine walls, 
producing shock, has been supposed to have caused it ; but in many 
of the fatal cases the symptoms have been rather those attending the 
passage of air into the veins, and it is easy to understand how air may 
have been introduced in this way into the large uterine sinuses. 

Simpson and Scanzoni have both tried with success the injection of 
carbonic acid gas into the vagina. Fatal results have, however, fol- 
lowed its employment, and Simpson expressed an opinion that the 
experiment should not be repeated. 

Of late years Pelzer's 1 method of injecting glycerin between the 
membranes and the uterine walls has been well spoken of by those 
who have used it. He injects from one to four ounces by means of a 
small syringe introduced some three or four inches within the cervix. 
The svringe, as well as the glycerin itself, must be sterilized by boil- 
ing, and care must be taken to fill the syringe up to the tip of the 
nozzle, so as to avoid any risk from the injection of air. The glycerin 
seems to act partly by separating the membranes from the uterine 
wall, partly by its hygrometric property, which leads to the absorption 
of the liquor amnii, and consequent contraction of the uterus. Pains 
have generally commenced within six hours of the injection, and labor 
has then progressed satisfactorily to its end. This method is simple, and 
apparently devoid of the risks attending the uterine douche, but further 
experience is necessary to estimate its practical value. 

Simpson originally induced labor by passing the uterine sound 
within the os, and up toward the fundus, and, when it had been in- 
serted to a sufficient extent, moving it slightly from side to side. He 
was led to adopt this procedure in the belief that we might thus 
closely imitate the separation of the decidua, which occurs previous to 
labor at term. Uterine contractions were induced with certainty and 
ease, but it was found impossible to foretell what time might elapse 
between the commencement of labor and the operation, which had 
frequently to be performed more than once. He subsequently modi- 
fied this procedure by introducing a flexible male catheter, Avithout a 
stilette, which he allowed to remain in the uterus until contractions 
were excited. This plan is much used in Germany, and is now that 
which is also most frequently adopted in England. It is simple 
and very efficacious, pains coming on almost invariably within 
twenty-four hours after the catheter or bougie is introduced. A theo- 
retical objection is the possibility of the catheter separating a portion 
of the placenta and giving rise to hemorrhage ; but in practice this 
has not been found to occur. The more deeply the catheter is intro- 

i Arch. f. Gvnak., xlii. 220. 



476 OBSTETRIC OPERATIONS. 

duced, the more certain aud rapid is its effect, and not less than seven 
inches should be pushed up within the os. It is not always easy to 
insert it so far, especially if a flexible catheter be used, which is apt to 
be too pliable to pass upward with ease. A solid bougie — male 
urethral bougie — should, therefore, be employed, or a hollow bougie 
containing a wire stilette, and I have found its introduction greatly 
facilitated by anaesthetizing the patient and passing the greater part 
of the hand into the vagina. In this way it can be pushed in very 
gently and without any risk of injury to the uterus. Previous to intro- 
ducing the bougie it should be thoroughly asepticized by the 1 : 1000 
solution, with which the vagina should also be well douched. There 
is some chance of rupturing the membranes while pushing it upward. 
This accident, indeed, cannot always be avoided, even when the greatest 
care is taken; but when it occurs, the puncture will be at a distance 
from the os, so that a small portion only of the liquor amnii will escape, 
and this can scarcely be considered a serious objection. It is always 
an advantage to allow the pains to come on gradually and in imita- 
tion of natural labor. Therefore, if, after the bougie has been inserted 
for a sufficient time, uterine contractions come on sufficiently strongly, 
we may leave the case to be terminated naturally; or, if they be com- 
paratively feeble, we may resort to accelerative procedures, viz., dila- 
tation of the cervix by the fluid bags, and subsequently the puncture 
of the membranes. In this way we have the labor completely under 
control ; and I believe this method will commend itself to those who 
have experience of it, as the simplest and most certain mode of induc- 
ing labor yet known, and the one most closely imitating the natural 
process. Of late I have been in the habit of combining dilatation of 
the cervix with this method, by means of a well-carbolized sponge- 
tent passed into the cervix after the bougie is in position. When the 
tent and bougie are removed, the cervix is found well dilated and 
ready for the passage of the child. This has been objected to as 
attended with septic risks ; but if the vagina is previously well 
douched with the sublimate solution, and the tent is not left in more 
than a few hours, I believe it to be practically quite safe, and it dilates 
the cervix more gently aud satisfactorily than any other method. 

It should not be forgotten that the child is immature, and that 
unusual care is likely to be required to rear it successfully. Indeed, 
the large infantile mortality after the induction of premature labor 
forms the most serious objection to the operation. Thus Ludwig 
Winckel l published twenty-five cases of induced labor on account of 
contracted pelvis. The mothers all recovered, but fourteen of the 
children were stillborn ; of the thirteen born alive, only seven survived 
a fortnight. If, therefore, we decide on the operation, the parents 
should be warned of the risks run by the child, although these are not 
of themselves a sufficient contra-indication to its adoption in suitable 
cases. We should, therefore, be careful to have at hand all the usual 
means of resuscitation ; and, as the mother may not be able to nurse 
at once, it would be a good precaution to have a healthy wet-nurse in 
readiness. 

i See Harris's note to 6th American edition. 



INDUCTION OF PREMATURE LABOR. 



477 



It is a matter of great importance to maintain the animal heat of 
premature children. For this purpose they are generally wrapped in 
cotton-wool and kept near the fire, but this is dirty and unsatisfactory. 
A far better and more hopeful procedure is to place the infant in an 
incubator or couveuse, 1 maintained at a uniform heat by means of a 
lamp, such as was first introduced by Taraier. I used a* modification 
of this apparatus, such as is here figured (Fig. 158), in a case in which 
the foetus could, at the most, haye been at the sixth month, keeping it 
for three months in the heated chamber, at a temperature varying 

Fig. 158. 




Hearson's thermostatic nurse, c. Tank of warm water interposed between upper and lower 
compartments (a and b). d d. Slips of wood supporting cradle, s. Capsule containing a liquid 
which boils at the temperature at which it Is desired to keep the chamber, a. From the centre of 
the capsule, s, a stiff wire passes out through the top of the apparatus, where it comes into contact 
with a light lever, v, which is hinged at f. From the free end of this lever hangs a damper (w), 
which rests on the top of the chimney under which the flame burns. If the temperature in the 
compartment a rises too high, the fluid in the capsule (s) boils and expands the capsule, thus 
raising the wire rod, which, acting on the lever v, at once lifts the damper (w) off the chimney, 
allowing the heat from the flame to escape by that outlet and preventing the further heating of 
the water, m. Aperture for entrance of air. o. Tray containing water. The centre of this tray is 
raised in the form of a cap (p), which fits over the aperture >r, through which the air enters. It is 
perforated all around its sides, so that the air passes through it horizontally, as shown by the 
arrows, instead of rising vertically. Another tray (x) of very coarsely perforated zinc, somewhat 
smaller than the first, is turned upside down within it, and over this is fitted the coarse canvas (x), 
the edges of which are tucked into the water all around. Thus the air entering is constantly 
moistened as well as heated, p. r. Flue shaped like the letter U, through which the heated air 
from the flame passes, so as to twice traverse the length of the. water-tank, and thus keep the water 
heated. In the top of the apparatus is a glass window through which the infant is kept in view. 
If a higher temperature than the boiling-point of the liquid within the capsule be desired, this 
can be obtained by moving the weight, t, along the lever toward the end to which the damper is 
attached. 

from 80° to 90° F., with a most satisfactory result. The apparatus is, 
however, costly, and requires a great deal of attention and supervision, 
so that it is clearly only suitable for use in maternity hospitals or in 
the houses of such patients as are able to incur the necessary expense. 

1 Auvard : " L»e la Couveuse pour Enfants," Arch, de Tocologie, Oct. 1383, p. 577. 



478 OBSTETRIC ORERATIONS. 



CHAPTER II. 

TUENING. 

History of the Operation. — Turning, by which we mean the alter- 
ation of the position of the foetus, and the substitution of some other 
portion of the body for that originally presenting, is one of the most 
important of obstetric operations, and merits careful study. It is also 
one of the most ancient, and was evidently known to the Greek and 
Roman physicians. Up to the fifteenth century, cephalic version — 
that in which the head of the foetus is brought over the os uteri — was 
almost exclusively practised, when Pare and his pupil Guillemeau taught 
the propriety of bringing the feet down first. It was by the latter 
physician especially that the steps of the operation were clearly defined ; 
and the French have undoubtedly the merit both of perfecting its per- 
formance and of establishing the indications which should lead to its 
use. Indeed, it was then much more frequently performed than in . 
later times, since no other means of effecting artificial delivery were 
known which did not involve the death of the child ; and practitioners, 
doubtless, acquired great skill in its performance, and were inclined to 
overrate its importance and extend its use to unsuitable cases. An 
opposite error was fallen into after the invention of the forceps, which 
for a time led to the abandonment of turning in certain conditions for 
which it was well adapted, and in which it has only of late years been 
again practised. 

Cephalic version has, since Pare wrote, been recommended and 
practised from time to time, but the difficulty of performing it satis- 
factorily was so great that it never became an established operation. 
Dr. Braxton Hicks has perfected a method by which it can be accom- 
plished with greater ease and certainty, and which renders it a legiti- 
mate and satisfactory resort in suitable cases. To him we are also 
indebted for introducing a method of turning without passing the 
entire hand into the cavity of the uterus, which, under favorable 
circumstances, is not only easy of performance, but deprives the oper- 
ation of one of its greatest dangers. 

The possibility of effecting version by external manipulation has 
been long known, and was distinctly referred to and recommended by 
Dr. John Pechey 1 so far back as the year 1698. Since that time it 
lias been strongly advocated by "Wigand and his followers ; and vari- 
ous authors in England, notably Sir James Simpson, have referred 
to the advantage to be derived from external manipulation assisting 
the hand in the interior of the uterus. In 1854 Dr. Wright, of 

1 The Complete Midwife's Practice, p. 142. 



TURNING. 479 

Cincinnati, advocated the application of the bimanual method in arm 
and shoulder presentations, chiefly with the view of effecting cephalic 
version. To Dr. Hicks, however, ineontestably belongs the merit of 
having been the first distinctly to show the possibility of effecting 
complete version in all cases in which the operation is indicated by 
combined external and internal manipulation, of laying down definite 
rules for its practice, and of thus popularizing one of the greatest im- 
provements in modern midwifery. 

The operation is entirely dependent for success on the fact that the 
child in utero is freely movable, and that its position may be artificially 
altered with facility. As long as the membranes are unruptured and 
the foetus is floating in the surrounding fluid medium, it is liable to 
constant changes in position, as may be readily demonstrated in the 
latter months of pregnancy ; and the operation, under these circum- 
stances, may be performed with the greatest facility. Shortly after the 
liquor anrnii has escaped there is still, as a rule, no great difficulty in 
effecting version ; but, as the body is no longer floating in the sur- 
rounding liquid, its rotation must necessarily be attended with some 
increased risk of injury to the uterus. If the liquor amnii has been 
long evacuated and the muscular structure of the uterus is strongly 
contracted, the foetus may be so firmly fixed that any attempt to move 
it is surrounded with the greatest difficulties, and may even fail en- 
tirely or be attended with such risks to the maternal structures as to 
be quite unjustifiable. 

Version may be required either on account of the mother or child 
alone ; or it may be indicated by some condition imperilling both, and 
rendering immediate delivery necessary. The chief cases in which 
it is resorted to, are those of transverse presentation, where it is 
absolutely essential ; accidental or unavoidable hemorrhage ; certain 
cases of contracted pelvis ; and some complications, especially prolapse 
of the funis. The special indications for the operation have been 
separately discussed under these subjects. 

Statistics and Dangers of the Operation. — The ordinary statis- 
tical tables cannot be depended on as giving any reliable results as to 
the risks of the operation. Taking all cases together, Dr. Churchill 
estimated the maternal mortality at one in sixteen, and the infantile as 
one in three. Like all similar statistics, they are open to the objection 
of not distinguishing between the results of the operation itself and 
of the cause which necessitated interference. Still, they are sufficient 
to show that the operation is not free from grave hazards, and that it 
must not be undertaken without due reflection. The principal dangers 
will be discussed as we proceed. It may suffice to mention here that 
those to the mother must vary with the period at which the operation 
is undertaken. If version be performed early, before the rupture of 
the membranes, or, in favorable cases, without the introduction of the 
hand into the interior of the uterus, the risk must of course be in- 
finitelv less than in those more formidable cases in which the waters 
have long escaped, and the hand and arm have to be passed into an 
irritable and contracted uterus. But even in the most unfavorable 
cases accidents may be avoided if the operator bears constantly in mind 



480 OBSTETRIC OPERATIONS. 

that the principal danger consists in laceration of the uterus or vagina 
from undue force being employed, or from the hand and arm not being 
introduced in the axis of the passages. There is no operation in which 
gentleness, absence of all hurry, and complete presence of mind are 
so essential. A certain number of cases end fatally from shock or 
exhaustion, or from subsequent complications. As regards the child 
the mortality is little, if at all, greater than in original breech and 
footling presentations. Nor is there any good reason why it should be 
so, seeing that cases of turning, after the feet are brought through the 
os, are virtually reduced to those of feet presentation, and that the 
mere version, if effected sufficiently soon, is not likely to add materially 
to the risk to which the child is exposed. 

The possibility of effecting version by external manipulation has been 
recognized by various authors, and was made the subject of an excellent 
thesis by Wigand, who clearly described the manner of performing the 
operation. In spite of the manifest advantages of the procedure, and 
the extreme facility with which it can be accomplished in suitable 
cases, it has by no means become the established custom to trust to it, 
and probably most practitioners have never attempted it, even under 
the most favorable conditions. The possibility of the operation is 
based on the extreme mobility of the foetus, before the membranes are 
ruptured. After the waters have escaped, the uterine walls embrace 
the foetus more or less closely, and version can no longer be readily 
performed in this manner. 

It may, therefore, be laid down as a rule that it should only be 
attempted when the abnormal position of the foetus is detected before 
labor has commenced, or in the early stage of labor, when the mem- 
branes are unruptured. It is also unsuitable for any but transverse 
presentations, for it is not meant to effect complete evolution of the 
foetus, but only to substitute the head for the upper extremity. It is 
useless whenever rapid delivery is indicated, for, after the head is 
brought over the brim, the conclusion of the case must be left to the 
natural powers. 

The manner of detecting the presentation by palpation has been 
already described (p. 130), and the success of the operation depends on 
our being able to ascertain the positions of the head and breech through 
the uterine walls. Should labor have commenced, and the os be dilated, 
the transverse presentation may be also made out by vaginal examina- 
tion. Should the abnormal presentation be detected before labor has 
actually begun, it is, in most cases, easy enough to alter it, and to bring 
the foetus into the longitudinal axis of the uterine cavity. Pinard 1 
recommends that after this has been done the foetus should be main- 
tained in position by a well-fitting elastic abdominal belt. It is seldom, 
however, discovered until labor has commenced, and even if it be 
altered the child is extremely apt to resume, in a short time, the faulty 
position in which it was formerly lying. Still there can be no harm 
in making the attempt, since the operation itself is in no way painful, 
and is absolutely without risk either to the mother or child. When 

1 De la Version par Manoeuvres extemes. Paris, 1878. 



TUKNING. 481 

the transverse presentation is detected early in labor, I believe it is 
good practice to endeavor to remedy it by external manipulation, and, 
if it fails, we may at once proceed to other and more certain methods of 
operating. The procedure itself is abundantly simple. The patient 
is placed on her back, and the position of the foetus ascertained by 
palpation as accurately as possible, in the manner already described. 
The palms of the hands being then placed over the opposite poles of 
the foetus, by a series of gentle gliding movements the head is pushed 
toward the pelvic brim, while the breech is moved in the opposite 
direction. The facility with which the foetus may sometimes be moved 
in this way can hardly be appreciated by those who have never at- 
tempted the operation. As soon as the change is effected, the long 
diameters of the foetus and the uterus will correspond, and vaginal 
examination will show that the shoulder is no longer presenting and 
that the head is over the pelvic brim. If the os be sufficiently dilated, 
and labor in progress, the membranes should now be punctured, and 
the position of the foetus maintained for a short time by external 
pressure until we are certain that the cephalic presentation is perma- 
nently established. If labor be not in progress, an attempt may at 
least be made to effect the same object by pads and a binder ; one pad 
being placed on the side of the uterus in the situation of the breech, 
and another on the opposite side in the situation of the head. 

On account of the difficulty of performing cephalic version in the 
manner usually recommended, it has practically scarcely been attempted, 
and, with the exception of some more recent authors, it is generally 
condemned by writers on systematic midwifery. Still, the operation 
offers unquestionable advantages in those transverse presentations in 
which rapid delivery is not necessary, and in which the only object of 
interference is the rectification of malposition ; for, if successful, the 
child is spared the risk of being drawn footling through the pelvis. 
The objections to cephalic version are based entirely on the difficulty 
of performance ; and, undoubtedly, to introduce the hand within the 
uterus, search for, seize, and afterward place the slippery head in the 
brim of the pelvis, could not be an easy process, even under the most 
favorable circumstances, and must always be attended with consider- 
able risk to the mother, Velpeau, who strongly advocated the oper- 
ation, was of opinion that it might be more easily accomplished by 
pushing up the presenting part, than by seizing and bringing down 
the head. Wigand more distinctly pointed out that the head could be 
brought to a proper position by external manipulation, aided by the 
fingers of one hand within the vagina. Braxton Hicks has laid down 
clear rules for its performance, which render cephalic version easy to 
accomplish under favorable conditions, and will doubtless cause it to 
become a recognized mode of treating malpositions. The number of 
cases, however, in which it can be performed must always be limited, 
since, as in turning by external manipulation alone, it is necessary that 
the liquor amnii should be still retained, or at least have only recently 
escaped ; that the presentation be freely movable about the pelvic brim 
aud that there be no uecessity for rapid delivery. Dr. Hicks does not 
believe protrusion of the arm to be a contraindication, and advises 

31 



482 OBSTETRIC OPERATIONS. 

that it should be carefully replaced within the uterus. When, how- 
ever, protrusion of the arm has occurred, the thorax is so constantly 
pushed down into the pelvis that replacement can neither be safe nor 
practicable, except under unusually favorable conditions, and podalic 
version will be necessary. 

Method of Performance. — It is impossible to describe the method 
of performing cephalic version more concisely and clearly than in Dr. 
Hicks's own words. " Introduce," he says, " the left hand into the 
vagina, as in podalic version ; place the right hand on the outside of 
the abdomen, in order to make out the position of the foetus and the 
direction of its head and feet. Should the shoulder, for instance, pre- 
sent, then push it with one or two fingers in the direction of the feet. 
At the same time pressure with the other hand should be exerted on 
the cephalic end of the child. This will bring the head down to the 
os ; then let the head be received on the tips of the two inside fingers. 
The head will play like a ball between the two hands ; it will be under 
their command, and can be placed in almost any part at will. Let the 
head then be placed over the os, taking care to rectify any tendency to 
face-presentation. It is as well, if the breech will not rise to the 
fundus readily, after the head is fairly in the os, to withdraw the hand 
from the vagina, and with it press up the breech from the exterior. 
The hand which is retaining gently the head from the outside should 
continue there for some little time, till the pains have insured the 
retention of the child in its new position and the adaptation of the 
uterine walls to its new form. Should the membranes be perfect, it is 
advisable to rupture them as soon as the head is at the os uteri ; during 
their flow and after, the head will move easily into its proper position. " 

The procedure thus described is so simple, and would occupy so 
short a time, that there can be no objection to trying it. Should we 
fail in our endeavors, we shall not be in a worse position for effecting 
delivery by podalic version, which can be proceeded with without 
removing the hand from the vagina, or in any way altering the posi- 
tion of the patient. 

The method of performing podalic version varies with the nature of 
each particular case. In describing the operation it has been usual to 
divide the cases into those in which the circumstances are favorable 
and the necessary manoeuvres easily accomplished, and those in which 
there are likely to be considerable difficulties and increased risk to the 
mother. This division is eminently practicable, since nothing can be 
more variable than the circumstances under which version may be 
required. Before describing the steps of the operation, it may be well 
to consider some general conditions applicable to all cases alike. 

In England the ordinary position on the left side is usually em- 
ployed. On the Continent and in America the patient is placed on 
her back, with the legs supported by assistants, as in lithotomy. The 
former position is preferable, not only as a matter of custom, and as 
involving much less fuss and exposure of the person, but because it 
admits of both the operator's hands being more easily used in concert. 
In certain difficult cases, when the liquor amnii has escaped and the 



TURNING. 483 

back of the child is turned toward the spine of the mother, the dorsal 
decubitus presents some advantages in enabling the hand to pass more 
readily over the body of the child ; but such cases are comparatively 
rare. The patient should be brought to the side of the bed, across 
which she should be laid, with the hips projecting over and parallel 
to the edge, the knees being flexed toward the abdomen, and separated 
from each other by a pillow or by an assistant. Means should be 
taken to restrain the patient if necessary, and prevent her involun- 
tarily starting from the operator, as this might not only embarrass his 
movements, but be the cause of serious injury. 

The exhibition of ana?sthetics is peculiarly advantageous. There is 
nothing which tends to facilitate the steps of the process so much as 
stillness on the part of the patient, and the absence of strong uterine 
contraction. "When the vagina is very irritable and the uterus firmly 
contracted around the body of the child, complete anaesthesia may 
enable us to effect version when without it we should certainly fail. 

It should be remembered that, since in all forms of version much 
manipulation is necessary, antiseptic precautions should be very rigidly 
enforced. 

The most favorable time for operating is when the os is fully dilated, 
before, or immediately after, the rupture of the membranes and the 
discharge of the liquor amnii. The advantage gained by operating 
before the waters have escaped cannot be overstated, since we can then 
make the child rotate with great facility in the fluid medium in which 
it floats. In the ordinary operation, in which the hand is passed into 
the uterus, it is essential to wait until the os is of sufficient size to 
admit of its being introduced with safety. This may generally be 
done when the os is the size of a crown-piece, especially if it be soft 
and yielding. 

The practice followed with regard to the hand to be used in turning 
varies considerably. Some accoucheurs always employ the right hand, 
others the left, and some one or other according to the position of the 
child. In favor of the right hand, it is said that most practitioners 
have more power with it, and are able to use it with greater gentleness 
and delicacy. In transverse presentations, if the abdomen of the child 
be placed anteriorly, the right hand is said to be the proper one to use, 
on account of the greater facility with which it can be passed over the 
front of the child ; and in difficult cases of this kind when we are 
operating with the patient on her back, it certainly can be employed 
with more precision than the left. In all ordinary cases, however, the 
left hand can be introduced much more easily in the axis of the pass- 
ages, the ha<-k of the hand adapts itself readily to the curve of the 
sacrum, and, even when the child's abdomen lies anteriorly, it can be 
passed forward without difficulty so as to seize the i'vvt. These advan- 
tages are sufficient to recommend its use, and very little practice is 
required to enable the practitioner to manipulate with it as freely as 
with the right. If, in addition, we remember that the right hand is 
required to operate on the foetus through the abdominal Malls — and 
this is a point which should never be forgotten — we shall have abun- 
dant reasons for laying it down as a rule that the left hand should 



484 



OBSTETRIC OPERATIONS, 



generally be employed. Before passing the hand and arm they should 
be freely lubricated, with the exception of the palm, which is left 
untouched to admit a firm grasp being taken of the foetal limbs. It 
is also advisable to remove the coat, and bare the arm as high as the 
elbow. 

As it should be a cardinal rule to resort to the simplest procedure 
when practicable, it will be well to consider first the method by com- 
bined external and internal manipulation, without passing the hand 
into the uterus, and subsequently that which involves the introduction 
of the hand. 

Fig. 159. 




First stage of bi-polar version. 



Elevation of the head and depression of the breech. 
(After Baknes.) 



Turning" by Combined External and Internal Manipulation. — 
To effect podalic version by the combined method, it is an essential 
preliminary to ascertain the situation of the foetus as accurately as 
possible. It will generally be easy, in transverse presentations, to 
make out the breech and head by palpation ; while, in head presenta- 
tions, the fontanelles will show to which side of the pelvis the face is 
turned. The left hand is then to be passed carefully into the vagina, 
in the axis of the canal, to a sufficient extent to admit of the fingers 
passing freely into the cervix. To effect this, it is not always neces- 
sary to insert the whole hand, three or four fingers being generally 
sufficient. 

If the head lie in the first (o.l.a.) or fourth (o.l.p.) position, push 
it upward and to the left ; while the other hand, placed externally on 



TURNING. 



485 



the abdomen, depresses the breech toward the right (Fig. 159). By 
this means we act simultaneously on both extremities of the child's 
body, and easily alter its position. The breech is pushed down gently 



Fig. 160. 




Second stage of bi-polar version. Elevation of the shoulders and depression of the breech. 

(After Barnes.) 

but firmly, by gliding the hand over the abdominal wall. The head 
will now pass out of reach, and the shoulders will arrive at the os 
and will lie on the tips of the fingers. This is similarly pushed 



Fig. 161. 




Third stage of bi-polar version. Seizure of the knee and partial elevation of the head. 

(After Barnes.) 

upward in the same direction as the head (Fig. 160). the breech at the 
same time being still further depressed, until the knee comes within 
reach of the fingers, when (the membranes being now ruptured, if still 



486 OBSTETRIC OPERATIONS. 

unbroken) it is seized and pulled down through the os (Fig, 161). 
Occasionally the foot comes immediately over the os, when it can be 
seized instead of the knee. Version may be facilitated by changing 
the position of the external hand, and pushing the head upward from 
the iliac fossa, instead of continuing the attempt to depress the breech 
(Figs. 161 and 162). These manipulations should always be carried 
on in the intervals, and desisted from when the pains come on ; and 
when the pains recur with great force and frequency, the advantage of 
chloroform will be particularly apparent. In the second (o.D.A.) and 
third (o.d.p.) positions, the steps of the operation should be reversed ; 
the head is pushed upward and to the right, the breech downward and 
to the left. When the position cannot be made oat with certainty, it 

Fig. 162. 




Fourth stage of bi-polar version. Drawing down of the legs and completion of version. 

(After Barnes.) 

is well to assume that it is the first (o.l.a.), since that is the one most 
frequently met with ; and even if it be not, no great inconvenience is 
likely to occur. If the os be not sufficiently open to admit of de- 
livery being concluded, the lower extremity can be retained in its new 
position with one finger until dilatation is sufficiently advanced or 
until the uterus has permanently adapted itself to the altered position 
of the child, either of which results will generally be effected in a short 
space of time. 

In transverse presentations the same means are to be adopted, the 
shoulder being pushed upward in the direction of the head, while 
the breech is depressed from without. This is frequently sufficient 
to bring the knees within reach especially if the membranes are 



TURNING. 487 

entire, but version is much facilitated by pressing the head upward 
from without, alternately with depression of the breech. If the liquor 
amnii has escaped and the uterus is firmly contracted round the body 
of the child, it will be found impossible to eifect an alteration in its 
position without the introduction of the hand, and the ordinary 
method of turning must be employed. The peculiar advantage of the 
combined process is, that it in no way interferes with the latter, for, 
should it not succeed, the hand can be passed on into the uterus 
without withdrawal from the vagina (provided the os be sufficiently 
dilated), and the feet or knees seized and brought down. 

Turning with the hand introduced into the uterus, provided the 
waters have not or have only recently escaped and the os be sufficiently 
dilated, is an operation generally performed with ease. 

The first step, and one of the most important, is the introduction of 
the hand and arm. The fingers having been pressed together in the 
form of a cone, the thumb lying between the rest of the fingers, the 
hand, thus reduced to the smallest possible dimensions, is slowly and 
carefully passed into the vagina, in the axis of the outlet, in an inter- 
val between the pains, and passed onward in the same cautious manner 
and with a semi-rotatory motion until it lies entirely within the 
vagina, the direction of introduction being gradually changed from 
the axis of the outlet to that of the brim. If uterine contractions 
come on, the hand should remain passive until they are over. It 
should ever be borne in mind as one of the fundamental rules in per- 
forming version, that we should act only in the absence of pains, and 
then with the utmost gentleness — all force and violent pushing being 
avoided. The hand, still in the form of a cone, having arrived at the 
os, if this be sufficiently dilated, may be passed through at once. If 
the os be not quite open, but dilatable, the points of the fingers may 
be gently insinuated, and occasionally expanded, so as to press it open 
sufficiently to permit the rest of the hand to pass. AVhile this is 
being done the uterus should be steadied by the other hand placed 
externally, or by an assistant. If the presentation should not previ- 
ouslv have been made out with accuracy, we can now ascertain how 
to pass the hand onward, so that its palmar surface may correspond 
with the abdomen of the child. 

Rupture of the Membranes. — The membranes should now be 
ruptured — if possible during the absence of pain, so as to prevent the 
waters being forced out. The hand and arm form a most efficient 
plug, and the liquor amnii cannot escape in any quantity. Some 
practitioners recommend that, before rupturing the membranes, the 
hand should be passed onward between them and the uterine walls, 
until we reach the feet. By so doing we run the risk of separating 
the placenta ; besides, we have to introduce the hand much farther 
than may be necessary, since the knees are often found lying quite 
close to the os. As soon as the membranes are perforated, the hand 
can be passed on in search of the feet (Fig. 163). At this stage of 
the operation increased care is necessary to avoid anything like force ; 
and should a pain come on, the hand must be kept perfectly flat and 
still, and rather pressed on the body of the child than on the uterus. 



488 



OBSTETRIC OPERATIONS. 



If the pains be strong, much inconvenience may be felt from the com- 
pression • and were the onward movement continued, or the hand even 
kept bent in the conical form in which it was introduced, rupture of 
the uterine walls might easily be caused. This is not likely to occur 
in the class of cases now under consideration, for it is chiefly when 
the waters have long escaped that the progress of the hand is a matter 
of difficulty. Valuable assistance may now be given by pressing the 
breech downward from without, so as to bring the knees or feet more 
easily within the reach of the internal hand. Having arrived at the 
knees or feet, they may be seized between the fingers and drawn 

Fig. 163. 




Seizure of the feet when the hand is introduced into the uterus. 



downward in the absence of a pain (Fig. 164). This will cause the 
foetus to revolve on its axis, the breech will descend, and at the same 
time the ascent of the head may be assisted by the right hand from 
without. It is a question with many accoucheurs which part of the 
inferior extremities should be seized and brought down. Some recom- 
mend us to seize both feet, others prefer one only, while some advise 
the seizure of one or both knees. In a simple case of turning, before 
the escape of the waters, it does not matter much which of these plans 
is followed, since version is accomplished with the greatest ease by 
any one of them. The seizure of the knee, however, instead of the feet, 
offers certain advantages which should not be overlooked. It is gener- 
ally more accessible, affords a better hold (the fingers being inserted in 



TURNING. 



489 



the flexure of the ham), and, being nearer the spine, traction acts more 
directly on the body of the child. Any danger of mistaking the knee 
for the elbow may be obviated by remembering the simple rule that 
the salient angle of the former, when the thigh is flexed, looks toward 
the head of the child, of the latter toward its feet. Certain advantages 
may also be gained by bringing down one foot or knee only, instead of 
both. When one inferior extremity remains flexed on the body of the 
child, the part which has to pass through the os is larger than when 
both legs are drawn down, and consequently the os is more perfectly 
dilated, and less difficulty is likely to be experienced in the delivery 



Fig. 164. 




Drawing down of the feet and completion of version. 



of the rest of the body, so that the risk to the child is materially 
diminished. 

Simpson, whose views have been adopted by Barnes and other 
writers, recommends the seizing, if possible, in arm presentations, of 
the knee farthest from and opposite to the presenting arm, as by this 
means the body is turned round on its longitudinal axis, and the present- 
ing arm and shoulder more easily withdrawn from the os. Dr. Galabin 
has carefully investigated this point in a recent paper, 1 and contends 
that there is a greater mechanical advantage in seizing the leg which 

1 Obstet. Trans., vol. xix. p. 269. 



490 



OBSTETRIC OPERATIONS. 



is nearest to, and on the same side as, the presenting arm, and this, 
moreover, is generally more readily done. 

As soon as the head has reached the fundus, and the lower extremity 
is brought through the os, the ease is converted into a foot or knee 
presentation, and it comes to be a question whether delivery should 
now be left to Nature or terminated by art. This must depend to a 
certain extent on the case itself, and on the cause which necessitated 
version, but, generally, it will be advisable to finish delivery without 
unnecessary delay. To accomplish this, downward traction is made 
during the pains, and desisted from in the intervals (Fig. 165). As 

Fig. 165. 




Showing the completion of version. (After Barnes.) 



the umbilical cord appears, a loop should be drawn down ; aud if the 
hands be above the head, they must be disengaged and brought over 
the face, in the same manner as in an ordinary footling presentation. 
The management of the head, after it descends into the cavity of the 
pelvis, must also be conducted as in labors of that description. 

Turning in Placenta Praevia. — In cases of placenta prsevia the 
os will, as a rule, be more easily dilatable than in transverse pres- 
entations. Hicks's method offers the great advantage of enabling us 
to perform version much sooner than was formerly possible, since it 
only requires the introduction of one or two fingers into the os uteri. 
Should we not succeed by it, and the state of the patient indicates that 
delivery is necessary, we have at our command, in the fluid dilators, a 



TURNING 



491 



means of artificially dilating the os uteri which can be employed with 
ease and safety. Lf Ave have to do with a case of entire placental 
presentation, the hand should be passed at that point where the 
placenta seems to be least attached. This will always be better than 
attempting to perforate its substance, a measure sometimes recom- 
mended, but more easily performed in theory than in practice. If the 
placenta only partially presents, the hand should, of course, be inserted 
at its free border. It will frequently be advisable not to hasten 
delivery after the feet have been brought through the os, for they form 
of themselves a very efficient plug, and effectually prevent further 
loss of blood ; while, if the patient be much exhausted, she may have 
her strength recruited by stimulants, etc., before the completion of 
delivery. 



Fig. 166. 




Showing the use of the right hand in abdomino-anterior position. 



Turning 1 in Abdomino-anterior Positions. — In abdomino-ante- 
rior positions, in which the waters have escaped, and in which, there- 
fore, some difficulty may be reasonably anticipated, the operation is 
generally more easily performed with the patient on her back ; the 
right hand is then introduced iuto the uterus, and the left employed 
externally (Fig. 166). In this way the internal hand lias to be passed 
a shorter distance and in a less constrained position. The operator 
then sits in front of the patient, who is supported at the edge of the 
bed in the lithotomy position with the thighs separated, and the right 
hand is passed up behind the pubes and over the abdomen of the 
child. 

Difficult Cases of Arm Presentation. — The difficulties of turn- 
ing culminate in those unfavorable eases of arm presentation in which 
the membranes have been long ruptured, the shoulder and arm pressed 



492 OBSTETRIC OPERATIONS. 

down into the pelvis, and the litems contracted around the body of 
the child. The uterus being firmly and spasmodically contracted, the 
attempt to introduce the hand often only makes matters worse, by in- 
ducing more frequent and stronger pains. Even if the hand and arm 
be successfully passed, much difficulty is often experienced in causing 
the body of the child to rotate ; for we have no longer the fluid 
medium present in Avhich it floated and moved with ease, and the arm 
of the operator may be so cramped and pained by the pressure of 
the uterine walls as to be rendered almost powerless. The risk of 
laceration is also greatly increased, and the care necessary to avoid so 
serious an accident adds much to the difficulty of the operation. 

Value of Anaesthesia in Relaxing- the Uterus. — In these per- 
plexing cases various expedients have been tried to cause relaxation of 
the spasmodically contracted uterine fibres, such as copious venesection 
in the erect attitude until fainting is induced, warm baths, tartar emetic, 
and similar depressing agents. None of these, however, is so useful 
as the free administration of chloroform, which has practically super- 
seded them all, and often answers most effectually when given to its 
full surgical extent. 

The hand must be introduced with the precautions already described. 
If the arm be completely protruded into the vagina, we should pass 
the hand along it as a guide, and its palmar surface will at once indi- 
cate the position of the child's abdomen. No advantage is gained by 
amputation, as is sometimes recommended. When the os is reached, 
the real difficulties of the operation commence, and, if the shoulder be 
firmly pressed down into the brim of the pelvis, it may not be easy to 
insinuate the hand past it. It is allowable to repress the presenting 
part a little, but with extreme caution, for fear of injuring the con- 
tracted uterine parietes. Herman 1 has pointed out that in some cases 
the difficulty is increased by the shoulder of the prolapsed arm being 
caught beneath the contraction ring (Bandl's), and he advises that it 
should be released by pressing it toward the centre of the cervical 
canal. It is better to insinuate the hand past the obstruction, which 
can generally be done by patient and cautious endeavors. Having 
succeeded in passing the shoulder, the hand is to be pressed forward 
in the intervals, being kept perfectly flat and still on the body of the 
foetus when the pains come on. It is much safer to press on it than 
on the uterine walls, which might readily be lacerated by the projecting 
knuckles. When the hand has advanced sufficiently far, it will be 
better, for the reasons already mentioned, to seize and bring down one 
knee only. 

When the Foot is Brought Down but the Foetus "will not 
Revolve. — Even when the foot has been seized and brought through 
the os, it is by no means always easy to make the child revolve on its 
axis, as the shoulder is often so firmly fixed in the pelvic brim as not 
to rise toward the fundus. Some assistance may be derived from 
pushing the head upward from without, which, of course, would raise 
the shoulder along with it. If this should fail, we may effect our 

1 " Note on One of the Causes of Difficulty in Turning," Obst. Trans , vol. xxviii. p. 150. 



THE FORCEPS. 493 

object by passing a noose of tape or wire ribbon around the limb, by 
which traction is made downward and backward ; at the same time 
the other hand is passed into the vagina to displace the shoulder and 
push it out of the brim. It is evident that this cannot be done as long 
as the limb is held by the left hand, as there is no room for both hands 
to pass into the vagina at the same time. By this manoeuvre version 
may be often completed when the foetus cannot be turned in the 
ordinary Avay. Various instruments have been invented both for 
passing a fillet around the child's limb and for repressing the shoulder, 
but none of them can compete, either in facility of use or safety, with 
the hand of the accoucheur. 

Mutilation of the Foetus. — Should all attempts at version fail, no 
resource is left but the mutilation of the child, either by evisceration 
or decapitation. This extreme measure is, fortunately, seldom neces- 
sary, as with due care version may generally be effected, even under 
the most unfavorable circumstances. 1 



CHAPTER III. 

THE FORCEPS. 

Use of the Forceps in Modern Practice. — Of all obstetric opera- 
tions the most important, because the most truly conservative both to 
the mother and child, is the application of the forceps. In modern 
midwifery the use of the instrument is much extended, and it is now 
applied by some of our most experienced accoucheurs with a frequency 
which older practitioners would have strongly reprobated. That the 
injudicious and unskilful use of the forceps is capable of doing much 
harm, no one will for a moment deny. This, however, is not a reason 
for rejecting the recommendation of those who advise a more frequent 
resort to the operation, but rather for urging n the practitioner the 
necessitv of carefully studying the manner of performing it, and of 
making himself familiar with the cases in which it is easy or the 
reverse. Nothing but practice — at first on the dummy, and afterward 
in actual cases— can impart the operative dexterity which it should be 
the aim of every obstetrician to acquire, and without which there can 
be no assurance of his doing his duty to his patient efficiently. 

Description. — The forceps may best be described as a pair of arti- 
ficial hands by which the foetal head may be grasped and drawn through 
the maternal passages by vis a f route, when the vis h tergo is deficient. 
This description will impress on the mind the important action of the 
instrument as a tractor, to which all its other powers are subservient. 

1 See note, p. 525. 



494 



OBSTETRIC OPERATIONS. 



The forceps consists of two separate blades of a curved form, adapted 
to fit the child's head ; a lock by which the blades are united after 
introduction ; and handles which are grasped by the operator, and by 
means of which traction is made. It would be a wearisome and un- 
satisfactory task to dwell on all the modifications of the instrument 
which have been made, which are so numerous as to make it almost 
appear as if no one could practise midwifery with the least pretension 
to eminence, unless he has attached his name to a new variety of 
forceps. 

The Short Forceps. — The original instrument, invented by the 
Chamberiens, may be looked upon as the type of the short straight 
forceps, which has been more employed than any others and which, 
perhaps, finds its best representative in the short forceps of Denman 
(Fig. 167). Indeed, the only essential difference between the two is 

Fig. 167. 




Denman's short forceps. 



the lock of the latter, originally invented by Smellie, which is so 
excellent that it has been adopted in all British forceps ; and which, 
for facility of juncture, is much superior to either the French pivot or 
the German lock, while for firmness it is, for all practical purposes, as 
good as either. In this instrument the blades are seven and the handle 
four and three-eighths inches in length ; the extremities of the blades 
are exactly one inch apart, and the space between them at their widest 
part is two and seven-eighths inches. The blades measure one and 
three-fourths inches at their greatest breadth and spring with a regular 



THE FOHCEFS. 



495 



sweep directly from the lock, there being no shank. The blades are 
formed of the best and most highly tempered steel, to resist the strain 
to which they are occasionally subjected, and they are smooth and 
rounded on their inner surface, to obviate the risk of injury to the 
scalp of the child. 

The special advantage claimed for this form of instrument is that, 
the two halves being precisely similar, no care or forethought is 
required on the part of the practitioner as to which blade should be 
introduced uppermost — an advantage of no great value, since no one 
should undertake a case of forceps delivery who has not sufficient 
knowledge of the operation, and presence of mind enough, to obviate 
any risk from the introduction of the wrong blade first. On account 
of its shortness, and the want of the second or pelvic curve, it is only 
adapted for cases in which the head is low down in the pelvis, or 
actually resting on the perineum. 

The Pelvic Curve. — The question of the second or pelvic curve is 
one on which there is much difference of opinion. The forceps we are 
now considering, and the many modifications formed on the same plan, 
is constructed solely with reference to its grasp on the child's head, 
and without regard to the axes of the maternal passages. Conse- 
quently, were we to introduce it when the head was at the upper part 
of the pelvis, we could not fail to expose the soft parts to the risk of 
contusion, and (in consequence of the necessity of drawing more directly 
backward) unduly stretch and even lacerate the perineum. Hence it 
is now admitted by obstetricians, with few exceptions, that the second 
curve is essential before the complete descent of the head, although it 
is not absolutely so after this has taken place. The only circumstances 
under which a straight blade can possess any superiority are in certain 
cases of occipito-posterior position, in which it is found necessary to 
rotate the head around a large extent of the pelvis, 
when the circular sweep of a strongly curved instru- 
ment might prove injurious. Such cases, however, 
are of rare occurrence, and need in no way influ- 
ence the general employment of the pelvic curve. 

Zeigler's Forceps. — The short forceps usually 
employed in Scotland is the invention of the late 
Dr. Zeigler (Fig. 1 68), and is useful from the facility 
with which the blades may be introduced in accurate 
apposition to each other, a point which in practice is 
of no little value. In general size and appearance it 
closely resembles Denman's forceps, but the fenestra 
of the lower blade is continued down to the handle. 
In introducing, the lower blade is slipped over the 
handle of the other blade already in situ, and thus 
it is guided with great certainty into a proper 
position, locking itself as it passes on. This in- 
strument has the disadvantage of not having 
the second curve, but the facility of introduction 
has rendered it a great favorite with many who have been in the 
habit of employing it. 



Fig. 168 




Zeigler's forceps. 



496 



OBSTETRIC OPERATIONS, 



The Long" Forceps. — For cases in which the head is not on the 
perineum, or at least not quite low in the pelvis, a longer instrument 
is essential. To meet this indication Smellie invented the long 
forceps, which, like the shorter instrument, has been very variously 
modified. The most perfect instrument of the kind employed in 
Great Britain is that known as Simpson's forceps (Fig. 169), which 
combines many excellent points selected from the forceps of various 
obstetricians, as well as some original additions, and which, as a whole, 
was never surpassed, until Tarnier's or its modification was invented. 

Fig. 169. 




Simpson's forceps. 



The curved portions of the blades are six and one-quarter inches 
long, the fenestra measuring one and one-quarter inches in its widest 
part. The extremities of the blades are one inch asunder when 
the handles are closed, and three inches at their widest part. The 
object of this somewhat unusual width is to lessen the compressing 
power of the instrument, without in any way interfering with its action 
as a tractor. The pelvic curve is less than in most long forceps, so as 
to admit of the rotation of the head when necessary, without the risk 
of injuring the maternal structures. Between the curve of the blade 
and the lock is a straight portion or shank, measuring two and three- 
eighths inches, which, before joining the handle, is bent at right angles 
into a knee. This shank is a useful addition to all forceps, and is 



THE FORCEPS. 497 

essential in the long forceps to insure the junction of the blades beyond 
the parts of the mother, which might otherwise be caught in the lock 
and injured. The knees serve the purpose of preventing the blades 
from slipping from each other after they have been united. They also 
admit of one linger being introduced above the lock, and used as an 
aid in traction ; a provision which is made in some other varieties of 
long forceps by a semicircular bend in each shank. The handles, 
which in most British forceps are too small and smooth to afford a firm 
grasp, are serrated at the edge, and flattened from before backward, so 
as to fit the closed fist more accurately. At their extremities, near the 
lock, there are a pair of projecting rests, over which the fore and 
middle fingers may be passed in traction, and which greatly increase 
our power over the instrument. Although this and other varieties of 
the long forceps are specially constructed for application when the 
head is high in the pelvis, it auswers quite as well as the short forceps 
— indeed, in most respects, better — when the head has descended low 
down. It is a decided advantage for the practitioner to habituate him- 
self to the use of one instrument, with the application and power of 
which he becomes thoroughly familiar. It is a mere waste of sjDace 
and money for him to encumber himself with a number of instruments 
of various shapes and sizes, and he may be sure that a good pair of 
long forceps will be suitable for every emergency, and in any position 
of the head. 

The chief argument against the use of such an instrument in simple 
cases is its great power. This, however, is entirely based on a mis- 
conception. The existence of power does not involve its use, and the 
stronger instrument can be employed with quite as much delicacy and 
gentleness as the weaker. The remarks of Dr. Hodge 1 on this point 
are extremely apposite, and are well worthy of quotation. He says : 
" Certainly no man ought to apply the forceps who has not sufficient 
discretion to use no more force than is absolutely requisite for safe 
delivery. If, therefore, there is more power at command, he is not 
obliged to use it; while, on the contrary, if much power be demanded, 
he can, within the bounds of prudence, exercise it by the long forceps, 
but with the short forceps his efforts might be unavailing. Moreover, 
in cases of difficulty, the short forceps being used, the practitioner 
would be forced to make great muscular efforts ; while witli the long 
forceps, owing to the great leverage, such effort will be comparatively 
trifling, and, of course, the whole force demanded can be much more 
delicately, and at the same time efficiently, applied, and with more 
safety to the tissues of the child and its parent." 

Continental Forceps. — The forceps usually employed on the Con- 
tinent and in America differs considerably, both in appearance and 
construction, from those in use in England. As a rule it is a larger 
and more powerful instrument, joined by a pivot or button-joint, and 
it always possesses the second or pelvic curve. Of late years Simpson's 
forceps has been much employed in some parts of Germany. Tl 
chief objection to the Continental instruments is their cumbrousness 

» System of Obstetrics, p. 242. 
32 



](' 



498 



OBSTETRIC OPERATIONS, 



This is chiefly in the handles, which in many of them are forged in a 
piece with the blades, the part introduced within the maternal struc- 
tures not being materially different from the corresponding part of the 
English instrument. 

Tarnier's Forceps. — The forceps invented by Professor Tarnier 
(Fig. 170) has attracted considerable attention, and is highly esteemed 
by all who have used it. In this instrument traction is not made on 
the handles by which the blades are introduced as in ordinary forceps, 
but on a supplementary handle (a) subsequently attached to the blades 
near the lower opening of their fenestra? (6). The advantage claimed 
for this arrangement is that less force is required in traction, which can 



Fig. 170. 



Fig. 171. 





Tarnier's forceps. 



Simpson's axis-traction forceps. 
c,b. Traction handle. c,f. Line of traction. 



always be made in the proper axis of the pelvis ; that the blades are 
not likely to slip ; and that rotation of the head is not interfered 
with. The handles of the forceps, moreover, guide the operator to the 
direction in which he ought to pull, since all that is required is to 
keep the traction rods parallel to them. This instrument, however, 
although theoretically excellent, is somewhat too complicated for 
general use. 

Simpson's Axis-traction Forceps. — Prof. A. P. Simpson, of 
Edinburgh, has invented a modification of Tarnier's instrument 3 which 
he calls the " Axis-traction Forceps "• (Fig. 171). The supplementary 
handles are fixed to the blades, and the whole mechanism is much 
simpler than in Tarnier's forceps. This has been somewhat improved 
by Milne Murray, by making the instrument entirely of metal and 
lightening the handles, which are not used for traction. For many 
years I have used this type of forceps to the exclusion of every other 



THE FORCEPS. 499 

form, and have every reason to be satisfied with it, especially in the 
high forceps operatiou, in which it seems to me superior to any other 
instrument. Indeed, the facility with which it effects delivery in 
such cases is often very striking. 

Action of the Instrument. — The forceps is generally said to act in 
three different ways : 

First. As a tractor. 
Second. As a lever. 
Third. As a compressor. 

It is more especially as a tractor that the instrument is of value, and 
it is used with the greatest advantage when it is employed merely to 
supplement the action of the uterus which is insufficient of itself to 
effect delivery, or when, from some complication, it is necessary to 
complete labor with greater rapidity than can be accomplished by the 
unaided powers of Nature. In most cases traction alone is sufficient ; 
but in order that it may act satisfactorily, and that the instrument may 
not slip, a proper construction of the forceps, and a sufficient curvature 
of the blades, are essential. The want of these is the radical fault of 
many of the short, straight instruments in common use, which have a 
tendency to slip during our efforts at extraction. 

The forceps acts also as a lever, but this action has been greatly ex- 
aggerated. It is generally described as a lever of the first class, the 
power being at the handles, the fulcrum at the lock, and the weight at 
the extremities. There may possibly be some leverage power of this 
kind when the instrument is first introduced, and the handles held so 
loosely that one blade is able to Avork on the other. But, as ordinarily 
used, the handles are held with a sufficiently firm grasp to prevent this 
movement, and then the two blades practically form a single instru- 
ment. 

Galabin, who has studied this subject in detail, points out 1 that : 
" 1. The lever is formed by both blades of the forceps and the foetal 
head united in one immovable mass. As soon as the blades begin to 
slip over the head, the lever is decomposed, and the swaying movement 
ceases to have any mechanical advantage. 2. The power is applied to 
the handles in a slanting direction. The resistance or weight does not 
act at a point either between the former and the fulcrum, or beyond 
the fulcrum, but at a point in a plane nearly at right angles to the line 
joining these two points, and its direction is a line perpendicular to 
that plane of the pelvis in which the greatest section of the head is 
engaged ; that is to say, in the case of straight forceps, nearly parallel 
to the handles. The lever formed does not, therefore, strictly speak- 
ing, belong to any one of the three orders into which levers are com- 
monly divided. 3. The fulcrum is fixed partly by friction, partly by 
the combination of traction with oscillatory movements — in other 
words, by the power being directed in great measure downward, and 
only slightly to one side." 

He further shows that the pendulum motion of the forceps is super- 
fluous in all ordinary forceps operations, in which traction alone is 

1 Galabin : " Action of Midwifery Forceps as a Lever," Obst. Journ., vol. iv. p. 508. 



500 OBSTETRIC OPERATIONS. 

amply sufficient for delivery ; but that when the head is impacted, and 
great force is required for its extraction, a mechanical advantage may 
be gained from having recourse to an oscillatory movement, which 
should, however, be very limited, and only continued if found to effect 
distinct advance of the head. 

Regarding the compressive power of the instrument there has been 
much difference of opinion. There is no doubt that the forceps, espe- 
cially some of the foreign instruments in which the points nearly 
approach each other, is capable of exerting considerable compression 
on the head. It is, however, extremely problematical if this action be 
of real value. It is to be borne in mind that in cases of protracted 
labor the head has been already moulded and compressed, and the 
bones have been made to overlap each other to their utmost extent, by 
the sides of the pelvis. We can scarcely, therefore, expect to diminish 
the head much more by the forceps without employing an amount of 
force that will seriously endanger the life of the child. It is in cases 
of disproportion between the head and the pelvis, depending on slight 
antero-posterior contraction of the pelvic brim, that diminution of the 
child's head by compression would be most useful. Then, however, 
the pressure of the forceps is exerted on that portion of the head which 
lies in the most roomj^ diameter of the pelvis, where there is no want 
of space. If this pressure does not increase the opposite diameter, which 
is in apposition to the narrower portion of the pelvis, it can at least 
do nothing toward lessening it, and diminution of any other part of 
the child's head is not required. 

Dynamical Action of the Forceps. — The mere introduction of 
the forceps sometimes excites increased uterine action, through the 
reflex irritation induced by the presence of a foreign body in the 
vagina. This has been called the dynamical action of the forceps ; 
but it cannot be looked upon in any other light than that of an occa- 
sional accidental result. 

The circumstances indicating the use of the forceps have been sepa- 
rately considered elsewhere, and to recapitulate them here would only 
lead to needless repetition. I shall, therefore, now merely describe the 
mode of using the instrument. 

Before doing so it is well to repeat what has already been said as to 
the difference between what may be termed the high and low forceps 
operations. The application of the instrument when the head is low 
in the pelvis is extremely simple ; and when there is no disproportion 
between the head and the pelvis, and some slight traction is alone 
required to supplement deficient expulsive power, the operation, in the 
hands of any ordinarily well instructed practitioner, ought to be per- 
fectly safe both to the mother and child. It is very different when the 
head is arrested at the brim, or high in the pelvis. Then the applica- 
tion of the forceps is an operation requiring much dexterity for its 
proper performance, and must never be undertaken without anxious 
consideration. It is because these two classes of operations have been 
confused that the use of the instrument is regarded by many with such 
unreasonable dread. 



THE FORCEPS. 501 

Preliminary Considerations. — Before attempting to introduce the 
forceps, there are several points to which attention should be directed. 

1st. The membranes must, of course, be ruptured. 

2d. For the safe and easy application of the instrument, it is also 
advisable that the os should be fully dilated, and the cervix retracted 
over the head. Still these two points cannot be regarded, as many 
have laid down, as being sine qua non. Indeed, we are often com- 
pelled to use the instrument when, although the os is fully dilated, the 
rim of the cervix can be felt at some point of the contour of the head, 
especially in cases in which the anterior lip is jammed between the 
head and the pubes. Provided due care be taken to guard the cervical 
rim with the fingers of one hand, as the instrument is slipped past it, 
there need be no fear of injury from this cause. If the os be not fully 
dilated, but is sufficiently open to admit of the passage of the forceps, 
the operation, under urgent circumstances, may be quite justifiable, but 
it must necessarily be a somewhat anxious one. 

3d. The position of the head should be accurately ascertained by 
means of the sutures and fontanelles. Unless this be done, the opera- 
tion will always be hap-hazard and unsatisfactory, as the practitioner 
can never be in possession of accurate knowledge of the progress of 
the case. It may be that the occiput is directed backward ; and, 
although that does not contra-indicate the application of the forceps, 
it involves special precautions being taken. 

4th. The bladder and bowels should be emptied. 

Question of Administering Ansesthetics. — Before proceeding to 
operate, the question of anaesthesia will arise. In any case likely to 
be difficult it is of the greatest assistance to have the patient completely 
under the influence of an anaesthetic to the surgical degree, so as to 
have her as still as possible ; but, whenever this is deemed necessary, 
another practitioner should undertake the responsibility of the admin- 
istration. In simple cases I believe it is better to dispense with 
anaesthetics altogether, partly because they are apt to stop what pains 
there are, which is in itself a disadvantage, but chiefly because, under 
partial anaesthesia, the patient loses her self-control, is restless, and 
twists herself into awkward positions, which gives rise to the utmost 
difficulty and inconvenience in the use of the instrument. Moreover, 
if no anaesthetic be given, the patient can assist the operator by placing 
herself in the most convenient attitude. 

Description of the Operation. — In describing the method of apply- 
ing the forceps, I shall assume that we have to do with the simpler 
variety of the operation, when the head is low in the pelvis. Subse- 
quently I shall point out the peculiarities of the high operation. 

As to the position of the patient, I believe there can be no doubt of 
the superiority of that which is usually adopted in Great Britain. On 
the Continent and in America the forceps is always employed witli the 
patient lying on her back, a position involving much needless exposure 
of the person, and requiring more assistance from others. In certain 
cases of unusual difficulty the position on the back is of unquestionable.' 
utility, but we may, at least, commence the operation in the usual way 
and subsequently turn the patient on her back if desirable. In such 



502 



OBSTETRIC OPERATIONS 



cases Walcher 1 advocates the lithotomy position, with the legs hanging 
over the edge of the bed, but not touching the ground. It is claimed 
for this that the weight of the depending thighs stretches the sacro-iliac 
joints sufficiently to cause an appreciable increase in the conjugate 
diameter of the brim, estimated as from \ to J of an inch. In certain 
exceptional high forceps cases, when the head will not pass through 
the brim, it may be worth trying, and it is said to have been successful 
when it has been found impossible to extract with the axis-traction 
forceps in the usual position. It is, however, rarely applicable, and 
in private practice it would be very difficult to use. 

Much of the facility with which the blades are introduced depends 
on the patient being properly placed. Hence, although it gives rise to 
a little more trouble at first, I believe that it is always best to pay 
particular attention to this point, whether the high or low forceps 
operation be about to be performed. The patient should be brought 
quite to the side of the bed, with her nates parallel to and projecting 
somewhat over its edge. The body should lie almost directly across 
the bed, and nearly at right angles to the hips, with the knees raised 
toward the abdomen (Fig. 172). In this way there is no risk of the 
handle of the upper blade, when depressed in introduction, coming in 
contact with the bed. 

Fig. 172. 




''iiillffllLllillllijii 
Position of patient for forceps delivery and mode of introducing lower blade. 



Antiseptic Precautions. — Previous to use the blades should be 
carefully disinfected. This is best done by thoroughly heating them 
in the flame of a spirit lamp, or by boiling, and then placing them in 
hot water and creolin. They should then be lubricated with carbolized 
vaseline and placed ready to hand. 

These preliminaries having been attended to, we proceed to the 



i Centralblatt fur Gynak., 1889. 



THE FORCEPS. 503 

introduction of the blades, sitting by the side of the bed, opposite the 
nates of the patient. 

The important question now arises, In what direction are the blades 
to be passed ? The almost universal rule in our standard works is, 
that they must be passed as nearly as possible over the child's ears, 
without any reference to the pelvic diameters. Hence, if the head 
have not made its turn, but is lying in one oblique diameter, the blades 
would require to be passed in the opposite oblique diameter; in short, 
the position of the forceps, as regards the pelvis, must vary according 
to the position of the head. Some have even laid down the rule that 
the forceps is contra-indicated unless an ear can be felt — a rule that 
would very seriously limit its application, as in many cases in which 
it is urgently required it is a matter of great difficulty, and even im- 
possibility, to feel the ear at all. It is admitted that in the high 
forceps operation the blades must be introduced in the transverse 
diameter of the pelvis, without relation to the position of the head. 
On the Continent it is generally recommended that this rule should be 
applied to all cases of forceps delivery alike, whether the head be high 
or low, and I have now for many years adopted this plan, and passed 
the blades in all cases, whatever be the position of the head, in the 
transverse diameter of the pelvis, without any attempt to pass them 
over the bi-parietal diameter of the child's head. Dr. Barnes points 
out with great force that, do what we will, and attempt as we may to 
pass the blades in relation to the child's head, they find their way to 
the sides of the pelvis, and that the marks of the fenestra? on the head 
always show that it has been grasped by the brow and side of the 
occiput. Of the perfect correctness of this observation I have no 
doubt ; hence, it is a needless element of complexity to endeavor to 
vary the position of the blades in each case, and one which only con- 
fuses the inexperienced practitioner, and renders more difficult an 
operation which should be simplified as much as possible. While, 
therefore, it is of importance that the precise position of the head 
should be ascertained in order that we may have an intelligent notion 
of its progress, I do not think that it is essential as a guide to the 
introduction of the forceps. 

Method of Introducing the Lower Blade. — As a rule, the lower 
blade, lightly grasped between the tips of the index and middle fingers 
and the thumb, should be introduced first. Poised in this way, we 
have perfect command over it, and can appreciate in a moment any 
obstacle to its passage. Two or more fingers of the left hand are 
introduced into the vagina, and by the side of the head, as a guide. 
The greatest care must be taken, if the cervix be within reach, that 
they are passed within it, so as to avoid the possibility of injury. 

The handle of the instrument lias to be elevated, and its point slid 
gently along the palmar surface of the guiding fingers until it touches 
the head (Fig. 172). At first the blade should be inserted in the axis 
of the outlet, but as it progresses the handle must be depressed and 
carried backward. As it is pushed onward it is made to progress by 
a slight side-to-side motion, and it is of tin; utmost importance to bear 
in mind that the greatest gentleness must always be used. If any 



504 OBSTETRIC OPERATIONS. 

obstruction be felt, we are bound to withdraw the instrument, partially 
or entirely, and attempt to manoeuvre, not force, the point past it. As 
the blade is guided on in this way, it is made to pass over the con- 
vexity of the head, the point being always kept slightly in contact 
with it, until it finally gains its proper position. When fully inserted 
the handle is drawn back toward the perineum, and given in charge 
to an assistant. The insertion must be carried on only in the inter- 
vals between the pains, and desisted from during their occurrence ; 
otherwise there would be a serious risk of injuring the soft parts of 
the mother. 

Introduction of the Upper Blade. — The second blade is passed 
directly opposite to the first, and is generally somewhat more difficult 
to introduce, in consequence of the space occupied by the latter. It 
is passed along two fingers directly opposite the first blade, and with 
exactly the same precautions as to direction and introduction, except 
that at first its handle has to be depressed instead of elevated (Fig. 

The handle which was in charge of the assistant is now laid hold of 
by the operator, and the two handles are drawn together. If the 
blades have been properly introduced, there should be no difficulty in 
locking ; but, should we be unable to join them easily, we must with- 
draw one or other, either partially or entirely, and reintroduce it with 
the same precautions as before. We must also assure ourselves that 
no hairs, or any of the maternal structures, are caught in the lock. 




Introduction of the upper blade. 



Method of Traction. — When once the blades are locked we may 
commence our efforts at traction. To do this we lay hold of the 
handles with the right hand, using only sufficient compression to give 
a firm grasp of the head and to keep the blades from slipping. The 



THE FORCEPS. 



505 



left hand may be advantageously used in assisting and supporting the 
right during our efforts at extraction, and, at a late stage of the opera- 
tion, may be employed in relaxing the perineum when stretched by 
the head of the child. Traction must always be made in reference to 
the pelvic axes, being at first backward toward the perineum (Fig. 
174), in the direction of the axis of the brim, and as the head descends 
and the vertex protrudes through the vulva, it must be changed to 
that of the outlet (Fig. 175). If the axis-traction forceps is used, it 
is to be borne in mind that traction is to be made by the traction 
handle only, the handles of the instrument itself being left untouched 
after they are locked and the traction rods are united. By keeping 
these latter parallel to the handles of the forceps, traction can always 
be made in the proper direction. AVe must extract only during the 
pains ; and, if these should be absent, Ave must imitate them by acting 
at intervals. This is a point which deserves special attention, for 
there is no more common error than undue hurry in delivery. 

The only valid objection I know of against a more frequent resort 
to the forceps in lingering labor is, that the sudden emptying of the 
uterus, in the absence of pains, may predispose to hemorrhage ; and it 
cannot be denied that it is one of some weight. However, if due care 
be taken to operate slowly, and to allow several minutes to elapse be- 
tween each tractive effort, while at the same time uterine contractions 
are stimulated by pressure and support, this need not be considered 



Fig. 174. 




Forceps in position. Traction in the axis of the brim, downward and backward. 



a contra-indication. Besides direct traction we may impart to the 
instrument a gentle waving motion from handle to handle, which 
brings into operation its power as a lever; but this must be done only 
to a very slight extent, and must always be subservient to direct trac- 
tion. 



506 



OBSTETRIC OPERATIONS, 



Proceeding thus in a slow and cautious manner, carefully regulating 
the force employed according to the exigencies of the case, we shall 
perceive that the head begins to descend ; and its progress should be 
determined, from time to time, by the fingers of the unemployed hand. 

When the head lies in the oblique diameter, as it descends, in con- 
sequence of its perfect adaptation to the pelvic cavity it will turn into 
the antero-posterior diameter without any effort on the part of the 
operator, provided only that the traction be sufficiently slow and 
gradual. As the head is about to emerge, it is necessary to raise the 
handles toward the mother's abdomen. More than usual care is re- 
quired to prevent laceration of the perineum, which is always much 
stretched (Fig. 175). If, as often happens, the pains have now in- 
creased, and the perineum be very thin and tense, it may even be desir- 
able to remove the blades gently and leave the case to be terminated 
by the natural powers ; but if due precautions are used this need not 
be necessary. 

The peculiarities of forceps delivery in occipito-posterior positions 
have already been discussed (p. 339), and need not be repeated. 

High Forceps Operations. — When high forceps operation has been 
decided on, the passage of the blades will be found to be much more 
difficult, from the height of the presenting part, the distance which 

Fig. 175. 




Last stage of extraction. The handles of the forceps are being gradually turned upward 
toward the mother's abdomen. 



they must pass, and, in some cases, from the mobility of the head 
interfering with their accurate adaptation. The general principles of 
introduction and of traction are, however, identical. This operation 



THE FORCEPS. 507 

will very rarely be attempted before the head has entered or become 
fixed in the pelvic brim, for if it be freely movable above the brim, 
turning is preferable. If, however, from long draining away of the 
waters, or rigidity of the uterus, we are induced to attempt the opera- 
tion before the head has entered the brim, it must be fixed as much as 
possible by abdominal pressure. In guiding the blades to the head 
special care must be taken to avoid any injury of the soft parts, espe- 
cially if the cervix be not completely out of reach. For this purpose 
it may even be advisable to introduce the entire left hand as a guide, 
so as to avoid any possibility of injuring the cervix from not passing 
the instrument under its edge. 

Peculiar Method of Introducing- the Blades. — Some authors 
advise that, in such cases, the blade should be introduced at first oppo- 
site the sacrum, until the point approaches its promontory. It is then 
made to sweep round the pelvis, under the protecting fingers, till it- 
reaches its proper position on the head. This plan is advocated by 
Ramsbotham, Hall Davis, and other eminent practical accoucheurs, 
and it is certainly of service in some cases of difficulty ; especially 
when, from any reason, it is not possible to draw the nates over the 
edge of the bed, when the necessary depression of the handle of the 
upper blade is difficult to effect. It involves, however, a somewhat 
complicated manoeuvre, and it is seldom that the blades cannot be 
readily introduced in the usual way. 

In locking, the slightest approach to roughness must be carefully 
avoided, for the extremities of the blades are now within the cavity of 
the uterus, and serious injury might easily be inflicted. If difficulty 
be met with, rather than employ any force, one of the blades should 
be withdrawn and reintroduced in a more favorable direction. If 
the blades have shanks of sufficient length, there should be no risk of 
including the soft parts of the mother in the lock, which, in a badly 
constructed instrument, is an accident not unlikely to occur. 

Method of Traction. — After junction, traction must at first be 
altogether in the axis of the brim, and to effect this the handles must 
be pressed well backward toward the perineum. As the head descends 
it will probably take the usual turn of itself, without effort on the 
part of the operator, and the direction of the tractive force may be 
gradually altered to that of the axis of the outlet. If the pains be 
strong and regular, and there be no indication for immediate delivery, 
we may remove the forceps after the head has descended upon the 
perineum, and leave the conclusion of the case to Nature. This course 
may be especially advisable if the perineum and soft parts be unusually 
rigid ; but generally it is better to terminate labor without removing 
the instrument. 

Possible Dangers of Forceps Delivery. — Before concluding this 
subject, reference may be made to the possible dangers of the opera- 
tion. I would here again insist on the importance of distinguishing 
between the high and low forceps operations, which have been so 
unfortunately and unfairly confounded. Reasons have already been 
given for rejecting the statistics of the risks attending forceps delivery 
in the latter class of cases (p. 366), A formidable catalogue of 



508 OBSTETRIC OPERATIONS. 

dangers, both to mother and child, might easily be gathered from our 
standard works on obstetrics. Among the former the principal are 
lacerations of the uterus, vagina, and perineum ; rupture of varicose 
veins, giving rise to thrombus ; pelvic abscess from contusion of the 
soft parts ; subsequent inflammation of the uterus or peritoneum ; 
tearing asunder of the joints and symphyses ; and even fracture of the 
pelvic bones. A careful analysis of these, such as has been so well 
made by Drs. Hicks and Phillips, 1 proves beyond doubt that the 
application of the instrument is not so much concerned in their 
production as the protraction of the labor, and the neglect of the prac- 
titioner in not interfering sufficiently soon to prevent the occurrence 
of the evil consequences, afterward attributed to the operation itself. 
Many of these will be found to arise from the prolonged pressure on 
the soft parts within the pelvis and the subsequent inflammation or 
sloughing. To these causes may be referred with propriety most cases 
of vesico-vaginal fistula (p. 460), peritonitis, and metritis following 
instrumental labor. 

Lacerations and similar accidents may, however, result from an 
incautious use of the instrument. Slight lacerations of the mucous 
membrane of the vagina are probably far from uncommon. But if 
these cases were closely examined it would be found that the fault lay 
not in the instrument, but in the hand that used it. Either the blades 
were introduced without due regard to the axes of the pelvis, or they 
were pushed forward with force and violence, or an instrument was 
employed unsuitable to the case (such as a short straight forceps when 
the head was high in the pelvis), or undue haste and force in delivery 
were used. It would be manifestly unfair to lay the blame of such 
results upon the forceps, which, in the hands of a more judicious and 
experienced practitioner, would have effected the desired object with 
perfect safety. The instrument is doubtless unsafe in the hands of 
anyone who does not understand its use, just as the scalpel or ampu- 
tating knife would be in the hands of a rash and inexperienced 
surgeon. The lesson to be learnt seems to be, clearly, not that the 
dangers should deter us from the use of the forceps, but that they 
should induce us to study more carefully the cases in which it is 
applicable and the method of using it with safety. 

Possible Risks to the Child. — The dangers to the child are, prin- 
cipally, lacerations of the integuments of the scalp and forehead; 
contusion of the face ; partial, but temporary, paralysis of the face 
from pressure of a blade on the facial nerve ; depression or fracture of 
the cranial bones ; injury to the brain from undue pressure of the 
blades. These evils are of rare occurrence, and, when they do happen, 
generally result from improper management of the operation — such as 
undue compression, the use of improper instruments, or excessive and 
ill-directed efforts at traction — and cannot, therefore, be considered as 
in any way contra-indicating the use of the instrument. Many of 
the more common results, such as slight abrasions of the scalp or 
paralysis of the face, are transitory in their nature and of no real 
consequence. 

1 Obstet. Trans., vol. xiii. p. 55. 



THE VECTIS. — THE FILLET. 509 



CHAPTEK IT. 

THE VECTIS.— THE FILLET. 

The Vectis. — In connection with the subject of instrumental de- 
livery, it is essential to say something of the use of the vectis, on 
account of the value which was formerly ascribed to it, which was at 
one time so great in England that it became the favorite instrument 
in the metropolis ; Denman saying of it that even those who employed 
the forceps were " very willing to admit the equal, if not superior, 
utility and convenience of the vectis." Even at the present day there 
are practitioners of no small experience who believe it to be of occasional 
great utility, and use it in preference to the forceps in cases in which 
slight assistance only is required. In spite, however, of occasional 
attempts to recommend its use, the instrument has fallen into disfavor, 
and may be said to be practically obsolete. 

Nature of the Instrument. — The vectis, in its most approved form, 
consists of a single blade, not unlike that of a short straight forceps, 
attached to a wooden handle. A variety of modifications exists in its 
shape and size. The handle has been occasionally manufactured, for 
the convenience of carriage, with a hinge close to the commencement 
of the blade (Fig. 176), or with a screw at the point where the handle 
and blade join. The power of the instrument, and the facility of 
introduction, depend very much on the amount of curvature of the 
blade. If this be decided, a firmer hold of the head is taken and 
greater tractile force is obtained, but the difficulty of introduction is 
increased. 

When employed in the former way, the fulcrum is intended to be 
the hand of the operator ; but the risk of using the maternal structures 
as a point d'appui, and the inevitable danger of contusion and lacera- 
tion which must follow, constitute one of the chief objections to the 
operation. Its value as a tractor must always be limited and quite 
inferior to that of the forceps, while it is as difficult to introduce and 
manipulate. 

Cases in which it is Applicable. — The vectis lias been recom- 
mended in cases in which the low forceps operation is suitable, pro- 
vided the pains have not entirely ceased. There is no doubt that it 
may be quite capable of overcoming a slight impediment to the passage 
of the head. It is applied over various parts of the head, most com- 
monly over the occiput, in the same manner, and with the same 
precautions, as one blade of the forceps. Dr. Ramsbotham says : " We 
shall find it necessary to apply it to different parts of the cranium, and 
perhaps the face also, successively, in order to relieve tin; head from 
its fixed condition and favor its descent." Such an operation ob- 



510 



OBSTETRIC OPERATIONS, 



viously requires quite as much dexterity as the application of the 
forceps ; while, if we bear in mind its comparatively slight power and 
the risk of injury to the maternal structures, we must admit that the 
disuse of the instrument in modern practice is amply justified. 



Fig. 177. 



Fig. 176. 




u^' 



Vectis with hinged handle. 



Wilmot's fillet. 



The vectis may, however, find a useful application when employed 
to rectify malpositions, especially in certain occipito-posterior presenta- 
tions. This action of the instrument has already been considered (page 
338), and, under such circumstances, it may prove of service where the 
forceps is inapplicable. When so employed it is passed carefully over 
the occiput, and, while the maternal structures are guarded from injury, 
downward traction is made during the continuance of a pain. So 
used, its application is perfectly simple and free from danger, and for 
this purpose it may be retained as part of the obstetric armamen- 
tarium. 

The Fillet is the oldest of obstetric instruments, having been fre- 
quently employed before the invention of the forceps, and even in the 
time of Smellie it was much used in the metropolis. It has since com- 
pletely fallen out of favor as a scientific instrument, although its use is 
every now and again advocated, and it is certainly a favorite instru- 
ment with some practitioners. This is to be explained by the apparent 
simplicity of the operation, and the fact that it can generally be per- 
formed without the knowledge of the patient. The latter, however, is 
one strong reason why it should not be used. 

Nature of the Instrument. — The fillet consists, in its most im- 
proved form (that which is recommended by Dr. Eardley Wilmot 1 ) 

i Obst. Trans., vol. xv. p. 172. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 511 

(Fig. 177), of a slip of whalebone fixed into a handle composed of 
two separate halves which join into one. The whalebone loop is 
slipped over either the occiput or face, and traction used at the 
handle. 

"When applied over the face, after the head has rotated, it would 
probably do no harm ; but if it were so placed when the head was 
high in the pelvis, traction would necessarily produce extension of the 
chin before the proper time, and would thus interfere with the natural 
mechanism of delivery. If placed over the occiput, it is impossible 
to make traction in the direction of the pelvic axes, as the instrument 
will then infallibly slip. If traction be made in any other direction, 
there must be a risk of injuring the maternal structures, or of changing 
the position of the head. Hence there is every reason for discarding 
the fillet as a tractor, or as a substitute for the forceps, even in the 
simplest cases. 

It is quite possible that it may find a useful application in certain 
cases in which the vectis may also be used, viz., as a rectifier of mal- 
position ; and, from the comparative facility of its introduction, it 
would probably be the preferable instrument of the two. 



CHAPTEE V. 

OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 

Operations involving' the destruction and mutilation of the 
child were among the first practised in midwifery. Craniotomy Mas 
evidently known in the time of Hippocrates, as he mentions a mode 
of extracting the head by means of hooks. Celsus describes a similar 
operation, and was acquainted with the manner of extracting the foetus 
in transverse presentations by decapitation. Similar procedures were 
also practised and described by Aetius and others among the ancient 
writers. The physicians of the Arabian school not only employed 
perforators for opening the head, but were acquainted with instru- 
ments for compressing and extracting it. 

Religious Objections to Craniotomy. — Until the end of the seven- 
teenth century this class of operation was not considered justifiable in 
the case of living children ; it then came to be discussed whether the 
life of the child might not be sacrificed to save that of the mother. 
It was authoritatively ruled by the Theological Faculty of Paris that 
the destruction of the child in any case was mortal sin. "Si Ton ne 
peut tirer l'enfant sans le tuer, on ne pent sans peche mortel le tirer." 
This dictum of the Roman Church had great influence on Continental 
midwifery, more especially in France, where, up to a recent date, the 
leading obstetricians considered craniotomy to be only justifiable when 



512 OBSTETRIC OPERATIONS. 

the death of the foetus had been positively ascertained. Even at the 
present day there are not wanting practitioners who, in their praise- 
worthy objection to the destruction of a living child, counsel delay 
until the child has died — a practice thoroughly illogical, and only 
sparing the operator's feelings at the cost of greatly increased risk to 
the mother. In England the safety of the child has always been con- 
sidered subservient to that of the mother ; and it has been admitted 
that, in every case in which the extraction of a living foetus by any 
of the ordinary means is impossible, its mutilation is perfectly justi- 
fiable. 

Formerly Performed with Unjustifiable Frequency. — It must 
be admitted that the frequency with which craniotomy has been per- 
formed in England constitutes a great blot on British midwifery. 
During the mastership of Dr. Labbat, at the Rotunda Hospital, there 
is no record of the forceps having been applied at all in 21,867 labors. 
Even in the time of Clarke and Collins, when its frequency was much 
diminished, craniotomy was performed three or four times as often as 
forceps delivery. These figures indicate a destruction of foetal life 
which we cannot look back to without a shudder, and which, it is to 
be feared, justify the reproaches which our Continental brethren have 
cast upon our practice. Fortunately, professional opinion has now 
completely recognized the sacred duty of saving the infant's life when- 
ever it is practicable to do so; and British obstetricians now teach as 
carefully as those of any other nation the imperative necessity of using 
every endeavor to avoid the destruction of the foetus. 

Divisions of the Subject. — The operation now under consideration 
may be necessary : 1st, when the head requires either to be simply 
perforated, or afterward more completely broken up and extracted — 
an operation which has received various names, but is generally known 
in England as craniotomy, and which may or may not require to be 
followed by further diminution of the trunk ; 2d, when the arm pre- 
sents, and turning is impossible. This necessitates one of two pro- 
cedures — decapitation, with the separate extraction of the body and 
head, or evisceration. In both classes of cases similar instruments are 
employed, and those generally in use at the present time may be first 
briefly described. 

Instruments Employed. — The object of the perforator is to pierce 
the skull of the child, so as to admit of the brain being broken up 
and the consequent collapse and diminution in size of the cranium. 
The perforator invented by Denman, or some modification of it, has 
been principally employed. It requires the handles to be separated in 
order to open the blades, and this cannot be done by the operator him- 
self. This difficulty is overcome in the modification of Naegele's 
perforator used in Edinburgh, in which the handles are so constructed 
that they open the points when pressed together, and are separated by 
a steel rod with a joint at its centre to prevent their opening too 
soon. By this arrangement the instrument can be manipulated by one 
hand only. The sharp-pointed portion has an external cutting edge, 
with projecting shoulders at its base to prevent its penetrating too far 
into the cranium. Many modifications of these arrangements have 



OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 513 

since been contrived (Figs. 178, 179, 180). In some parts of the 
Continent a perforator is used constructed on the principle of the 
trephine; but this is vastly more difficult to work and has the great 
disadvantage of simply boring a hole in the skull, instead of splitting 
it up, as is done by the sharp-pointed instrument. 

The instruments for extraction are the crotchet and craniotomy 
forceps. 

Crotchets and Craniotomy Forceps. — The crotchet is a sharp- 
pointed hook of highly tempered steel, which can be fixed on some 
portion of the skull, either internal or external, traction being made 
by the handle. The shank of the instrument is either straight or 
curved (Figs. 181 and 182), the latter being preferable, and it is either 
attached to a wooden handle or forged in a single piece of metal. A 
modification of this instrument is known as Oldham's vertebral hook. 
It consists of a slender hook, measuring with its handle thirteen 



Fig. 178. 



Fig. 179. 



Fig. 180. 




Various forms of perforators. 



inches in length, which is passed through the foramen magnum and 
fixed in the vertebral canal, so as to secure a firm hold for traction. 
All forms of crotchets are open to the serious objection of being liable 
to slip, to break through the bone to which they are fixed, so wound- 
ing either the soft parts of the mother, or the fingers of the operator 
placed as a guard. Hence they are discountenanced by most recent 
writers, and may with propriety be regarded as obsolete instruments. 

Their place as tractors is well supplied by the more modern crani- 
otomy forceps (Fig. 183). These are intended to lay hold of the 
skull, one blade being introduced within the cranium, the other exter- 
nally, and, when a firm grasp has been obtained, downward traction is 
made. A second object it fulfils is to break away and remove portions 
of the skull when perforation and traction alone are insufficient to effect 
delivery. Many forms of craniotomy forceps are in use — some armed 

33 



514 OBSTETRIC OPERATIONS. 

with formidable teeth; others, of simpler construction, depending on 
their rougheued and serrated internal surfaces for firmness of grasp. 

Figs. 381, 182. 




Crotchets. 



For general use there is no better instrument than the cranioclast of 
Sir James Y. Simpson (Fig. 184), which admirably fulfils both these 
indications. It consists of two separate blades fastened by a button 
joint. The extremities of the blades are of a duck-billed shape, and 
are sufficiently curved to allow of a firm grasp of the skull being 
taken : the upper blade is deeply grooved to allow the lower to sink 
into it, and this gives the instrument great power in fracturing the 
cranial bones, when that is found to be necessary. It need not, how- 
ever, be employed for the latter purpose ; and the blades, being serrated 
on their under surface, form as perfect a pair of craniotomy forceps 
as any in ordinary use. Provided with it, we are spared the necessity 
of procuring a number of instruments for extraction. 

Cephalotribe. — Amongst modern improvements in midwifery there 
are few which have led to more discussion than the use of the cephalo- 
tribe. This instrument, originally invented by Baudelocque, was long 
employed on the Continent before it was used in England, the preju- 
dice against it being no doubt due to its formidable size and appear- 
ance. Of late years many r of our leading obstetricians have used 
it in preference to either the crotchet or craniotomy forceps, and have 
materially modified and improved its construction, so that the most ob- 
jectionable features of the older instruments are now entirely removed. 

The cephalotribe consists of two powerful solid blades, which are 
applied to the head after perforation, and approximated by means of a 
screw so as to crush the cranial bones, and after this it may also be 
used for extraction. The peculiar value of the instrument is that, 
when properly applied, it crushes the firm base of the skull, which is 
left untouched by craniotomy ; or, if it does not, it at least causes the 
base to turn edgewise within the blades, so as to be in a more favorable 
position for extraction. Another and specially valuable property is 
that it crushes the bones within the scalp, which forms a most efficient 
protective covering to their sharp edges. In this way one of the 
principal dangers of craniotomy — the wounding of the maternal pas- 
sages by spiculse of bone — is entirely avoided. 

The cephalotribe, therefore, acts in two ways — as a crusher and as 
a tractor. Some obstetricians believe the former to be its more im- 
portant use, and even maintain that the cephalotribe is unsuited for 
traction. This view is specially maintained by Pajot, who teaches 



OPERATIONS INVOLVING DESTRUCTION OF FGETUS. 515 



that, after the size of the skull has been diminished by repeated 
crushings, its expulsion should be left to the natural powers. There 
are some grounds for believing that in the greater degrees of obstruc- 
tion the tractile power of the instrument should not be called into use ; 
but, in the large majority of cases, the facility with which the crushed 
head may be withdrawn by it constitutes one of its chief claims to the 
attention of the obstetrician. Xo one who has used it in this way, 
and experienced the rapid and easy manner in which it accomplishes 
delivery, can have any doubt on this point. 

There is every reason to believe that cephalotripsy will be much 
extended in Great Britain, and that it will be considered, as I believe 
it unquestionably deserves to be, the ordinary operation in cases re- 
quiring destruction of the foetus. The comparative merits of cephalo- 
tripsy and craniotomy will be subsequently considered. 



Fig. 183. 



Fig. 184. 





Craniotomy forceps. 



Simpson's cranioclast. 



The most perfect cephalotribe is probably that known as Braxton 
Hicks's (Fig. 185), which is a modification of Simpson's. It is not 
of unwieldly size, but sufficiently powerful for any case, and not ex- 
travagant in price. The blades have a slight pelvic curve, which 
materially facilitates their introduction, yet not sufficiently marked to 
interfere with their being slightly rotated after application. Dr. Kidd, 
of Dublin, prefers a straight blade; while Dr. Matthews Duncan 
thought it better to use a somewhat bulkier instrument, modelled on 
the type of the Continental cephalotribes. The principle of action of 
ail these is identical, and their differences are not of very material im- 
portance. 

Section of the Skull by the Forceps-saw, or Bcraseur. — 
Another mode of diminishing the foetal skull is by removing it in sec- 
tions. The object is aimed at in the forceps-saw of Van Huevel, which 
consists of two large blades, not unlike those of the cephalotribe iu 



516 OBSTETRIC OPERATIONS. 

appearance. Within these there is a complicated mechanism, working 
a chain-saw from below upward, which cuts through the foetal skull; 
the separated portions are subsequently withdrawn piecemeal. This 
instrument is highly spoken of by the Belgian obstetricians, who believe 
that it affords by far the safest and most effectual way of reducing the 
bulk of the foetal skull. A somewhat similar instrument has been 
invented by Tarnier. In Great Britain these instruments are practi- 
cally unknown ; and, although they must be admitted to be theoretically 
excellent, the complexity and cost of the apparatus have always stood 
in the way of their being used. 

Fig. 185. 




Hicks' s cephalotribe. 



Dr. Barnes has suggested that the same results may be obtained by 
dividing the head with a strong wire ecraseur. So far as I know, this 
suggestion has never yet been carried out in practice, not even by 
himself, and therefore it is not possible to say much about it. I 
should imagine, however, that there would be considerable difficulty 
in satisfactorily passing the loop of wire over the skull in a pelvis in 
which there is any well-marked deformity. 

Cases requiring* Craniotomy. — The most common cause for which 
craniotomy or cephalotripsy is performed is a want of proper propor- 
tion between the head and the maternal passages. This may arise 
from a variety of causes. The most important, and that most often 
necessitating the operation, is osseous deformity. This may exist 
either in the brim, cavity, or outlet, and it is most often met with in 
the antero-posterior diameter of the brim. Obstetric authorities differ 
considerably as to the precise amount of contraction which will pre- 
vent the passage of a living child at term. Thus Clarke and Burns 
believe that a living child cannot pass through a pelvis in which the 
antero-posterior diameter at the brim is less than three and one-quarter 
inches. Ramsbotham fixes the limit at three inches, and Osborne and 
Hamilton at two and three-quarters inches. The latter is the extreme 
limit at which the birth of a living child is possible ; but there can 
be no doubt that, under favorable circumstances, it may be possible to 
draw the foetus, after turning, through a pelvis of that size. The 
opposite limit of the operation is still more open to discussion. Various 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 517 

authorities have considered it quite possible to draw a mutilated foetus 
through a pelvis in which the anteroposterior diameter does not exceed 
one and one-half inch, and, indeed, have succeeded in doing so. But 
then there must be a fair amount of space in the transverse diameter 
of the pelvis to admit of the necessary manipulations. If there be a 
clear space here of three inches and upward, it is no doubt possible to 
deliver per vias naturcdes ; but in such extreme deformities, the diffi- 
culties are so great, and the bruising of the maternal structures so 
extensive, that it becomes an operation of the greatest possible severity, 
with results nearly as unfavorable to the mother as the Cesarean 
section. Hence some Continental authorities have not scrupled to 
prefer the latter operation in the worst forms of pelvic deformity. The 
rule in English practice always has been that craniotomy must be per- 
formed whenever it is practicable ; and there can be no doubt that it 
is, generally speaking, the right one. 

Between from two and three-quarters to three inches antero-posterior 
diameter in the one direction, and one and three-quarters inches in the 
other, may be said to be the limits of craniotomy, provided, in the 
latter case, there be a fair amount of space in the transverse diameter. 
The same limits may be laid down with regard to tumors or other 
sources of obstruction. 

There are a few other conditions in which craniotomy is justifiable, 
independently of pelvic contraction, such as certain conditions of the 
soft parts which are supposed to render the passage of the head pecu- 
liarly dangerous to the mother. Among them may be mentioned 
swelling and inflammation of the vagina from the length of the pre- 
vious labor, bands and cicatrices of the vagina, and occlusion and 
rigidity of the os. It is hardly too much to say that with a proper 
use of the resources of midwifery, the destruction of a living foetus 
for any of these conditions might be obviated. The most common of 
them is undoubtedly swelling of the soft parts causing impaction of 
the head, an occurrence which ought to be invariably prevented by 
a timely use of the forceps. Should interference unfortunately be 
delayed until impaction has actually taken place, doubtless no other 
resource but craniotomy would be left ; but such cases, it is to be 
hoped, are now of rare occurrence in British practice. Undue rigidity 
of the os can be overcome by dilatation with the caoutchouc bags, or, 
in more serious cases, by incision, which would certainly be less 
perilous to the mother than dragging even a mutilated foetus through 
the small and rigid aperture. In the case of bands and cicatrices in 
the vagina, dilatation or incision will generally suffice to remove the 
obstruction ; but even were this not so here, as in excessive rigidity of 
the perineum, it would be better that slight lacerations should take 
place than that the child should be killed. 

Certain complications of labor are held to justify craniotomy, 
such as rupture of the uterus, convulsions, and hemorrhage. The 
application of the forceps or turning will generally answer our purpose 
equally well, especially as we have the means of dilating the os suffi- 
cientlv to admit of one or other of them being performed when the 
natural dilatation is not sufficient. Craniotomy in rupture of the 



518 OBSTETRIC OPERATIONS. 

uterus will also be rarely indicated, as we have seen that laparotomy 
appears to afford a better chance to the mother in those cases in 
which the foetus has partially or entirely escaped from the uterine 
cavity. 

Want of proportion between the foetus and the pelvis, depending on 
undue size of the head, either natural or the result of disease, may 
render the operation essential. In the former of these cases we shall 
generally have first attempted delivery with the forceps, and, if it has 
failed, there can be no doubt as to the propriety of lessening the bulk 
of the head by perforation, unless we determine to attempt delivery by 
symphyseotomy (see p. 541). 

In most obstetric works we are recommended to perforate rather 
than apply the forceps, when we are convinced that the child has 
ceased to live. This advice is based on the greater facility with which 
craniotomy can be performed, and its supposed greater safety to the 
mother. There can be no doubt of the ease with, which the child can 
be extracted after perforation, when the pelvis is not contracted ; and, 
if we could always be sure of our diagnosis, the rule might be a good 
one. Before acting on it, however, we must bear in mind the extreme 
difficulty of positively ascertaining the death of the foetus. Of the 
signs usually relied on for this purpose, there are scarcely any which 
are not open to fallacy, except peeling of the scalp, and disintegration 
of the cranial bones, which do not take place unless the child has been 
dead for a length of time, and are, therefore, useless in most instances. 
Discharge of the meconium constantly takes place when the child is 
alive ; a cold and pulseless prolapsed cord may belong to a twin ; and 
a foetal heart may become temporarily inaudible, although the child is 
not dead. If, indeed, we have carefully watched the foetal heart all 
through the labor, and heard it become more and more feeble, and 
finally stop altogether, we might be certain that the child has died ; 
but surely such observations would rather indicate an early recourse 
to the forceps or version, so as to obviate the fatal result we know to 
be impending. 

Perforation of the After-coming- Head. — In certain breech pres- 
entations, or after turning, it may be found impossible to extract the 
head without diminishing its size by perforating behind the ear. In 
such cases we know to a certainty whether the child be alive or dead, 
before resorting to the operation. 

The preliminary step, whether we resort to cephalotripsy or crani- 
otomy, is perforation, which will, therefore, be first described. In the 
former the desirability of first perforating the head is not always 
recognized. To endeavor to crush the head without perforating is 
needlessly to increase the difficulties of the case, and it should be 
remembered, as a cardinal rule, that perforation is an essential pre- 
liminary to the proper use of the cephalotribe. 

Before perforating we must carefully ascertain the exact relation of 
the os to the presenting part, since, in many cases, the operation is 
performed before the os is fully dilated, when there is a risk of wound- 
ing the cervix. Two or more fingers of the left hand should be passed 
up to the head and placed against the most prominent part of the 



OPERATIONS INVOLVING DESTRUCTION OF FfflTUS. 519 

parietal bone. Under these, used as guard (Fig. 186), the perforator 
should be cautiously introduced until the scalp is reached. It is im- 
portant to fix on a bony part of the skull, and not on a suture or 
fontanelle, for puncture, because our object is to break up the vault of 
the cranium as much as possible, so as to allow the skull to collapse. 
When the instrument has reached the point we have selected, it should 
be made to penetrate the scalp and skull with a semi-rotatory boring 



Fig. 186. 




Perforation of the skull. 



motion, and advanced until it has sunk up to the rests, which will 
oppose its further progress. Occasionally considerable force will be 
necessary to effect penetration, more especially if the scalp be swollen 
by long-continued pressure ; and this stage of the operation will be 
facilitated by causing an assistant to steady the head by pressure on 
the foetus through the abdomen, more especially if it be still free above 
the pelvic brim. We must then press together the handles of the 
instrument, which will have the effect of widely separating the cutting 
portion, and making an incision through the bones. After this the 
point should be turned around, and again opened at right angles to 
the former incision, so as to make a free crucial opening. During this 
process care must be taken to bury the perforator in the skull up to 
the rests, so as to avoid the possibility of injuring the maternal soft 
parts. The instrument should now be introduced within the skull 



(>20 OBSTETRIC OPERATIONS. 

and moved freely about, so as to thoroughly and completely break up 
the brain. Especial care must be taken to reach the medulla oblongata 
and base of the brain, for, if these are not destroyed, we might subject 
ourselves to the distress of extracting a child in whom life was not 
extinct. If this part of the operation be thoroughly performed, there 
will be no necessity for washing out the brain by the injection of warm 
water, as is sometimes recommended, for the broken-up tissue will 
escape freely through the opening made by the perforator. 

The perforation of the after-coming head does not generally offer 
any particular difficulty. It is accomplished in the same manner, the 
child's body being well drawn out of the way by an assistant. The 
point of the perforator, carefully guarded by the finger, is guided up 
to the occiput, or behind the ear, where it is inserted, or perforation 
may be performed through the hard palate. 

If there be no necessity for very rapid delivery, and the pains be 
still present, it is often advisable to wait ten minutes or a quarter of 
an hour before proceeding to extract. This delay will allow the skull 
to collapse and become moulded to the cavity of the pelvis, when forced 
down by the pains, and possibly the natural efforts may suffice to finish 
the labor in that time ; or, at least, the head will have descended 
further, and will be in a better position for extraction. Should per- 
foration be required after having failed to deliver with the forceps — 
and this is only likely to be the case when the obstruction is com- 
paratively slight — it is certainly a good plan to perforate without 
removing the forceps, which may then be used as tractors. 

We have now to decide on the method of extraction, and our choice 
generally lies between the cephalotribe and the craniotomy forceps, 
although in some few cases, in which the pelvic contraction is slight, 
version may be advantageously employed. Some have even advised 
version as a preliminary step in all cases requiring craniotomy, the 
skull being perforated through the roof of the mouth, and subsequently 
crushed with the cephalotribe. 1 

Comparative Merits of Cephalotripsy and Craniotomy. — Those 
who have used both must, I think, admit that in any ordinary case, in 
which the obstruction is not great, and only a comparatively slight 
diminution in the size of the head is required, cephalotripsy is infi- 
nitely the easier operation. The facility with which the skull can be 
crushed is sometimes remarkable, and those who will take the trouble 
to read the reports of the operation published by Braxton Hicks, Kidd, 
and others, cannot fail to be struck with the rapidity with which the 
broken-down head may often be extracted. This is far from being the 
case with the craniotomy forceps, even when the obstruction is moder- 
ate only; for it may be necessary to use considerable traction, or the 
blades may take a proper grasp with difficulty, or it may be essential 
to break down and remove a considerable portion of the vault of the 
cranium before the head is lessened sufficiently to pass. During the 
latter process, however carefully performed, there is a certain risk of 
injuring the maternal structures, and, in the hands of a nervous or 

1 See Donald on " Methods of Craniotomy," Obst. Trans., vol. xxxi. p. 28. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 5^1 

inexperienced operator, this danger, which is entirely avoided in ceph- 
alotripsy, is far from slight. The passage of the blades of the cephalo- 
tribe is by no means difficult, and I think it must be admitted that the 
possible risks attending it are comparatively small. On account, there- 
fore, of its simplicity and safety to the maternal structures, I believe 
cephalotripsy to be decidedly the preferable operation in all cases of 
moderate obstruction. 

When we approach the lower limit, and have to do with a very 
marked amount of pelvic deformity, the two operations stand on a 
more equal footing. Then the deformity may be so great as to render 
it difficult to pass the blades of even the smallest cephalotribe sufficiently 
deep to grasp the head firmly, and even when they are passed, the space 
is often so limited as to impede the easy working of the instrument. 
Besides this, repeated crushings may be required to diminish the skull 
sufficiently. I attach but little importance to the argument that the 
diminution of the skull in one diameter increases its bulk in another. 
The necessity of removing and replacing the blades on another part of 
the skull, and of repeating this perhaps several times, in the manner 
recommended by Pajot, is a far more serious objection. To do this in 
a contracted pelvis involves, of necessity, the risk of much contusion. 
Fortunately cases of this kind are of extreme rarity, much more so 
than is generally believed, but when they do occur they tax the resources 
of the practitioner to the utmost. 

On the whole, the conclusion I would be inclined to arrive at with 
regard to the two operations is, that in all ordinary cases omphalo- 
tripsy is safer and easier, whereas in cases with considerable pelvic 
deformity, the advantages of cephalotripsy are not so well marked, 
and craniotomy may even prove to be preferable. 

The first step in using the cephalotribe is the passage of the blades. 
These are to be inserted in precisely the same manner, and with the 
same precautions, as in the high forceps operation. In many cases the 
os is not fully dilated, and it is absolutely essential to pass the instru- 
ment within it. Special care should, therefore, be taken to avoid any 
injury to its edges, and, for this purpose, two or three fingers of the left 
hand, or even the whole hand, should be passed high up, so as thoroughly 
to protect the maternal structures. In order that the base of the skull 
may be reached and effectually crushed, the blades must be deeply 
inserted, and, in doing this, great care and gentleness must be used. As 
the projecting promontory of the sacrum generally tilts the head for- 
ward, the handles of the instrument, after locking, must be well pressed 
backward toward the perineum. If the blades do not lock easily, or 
if any obstruction to their passage be experienced, one of them must 
be withdrawn and reintroduced, just as in a forceps operation. Care 
must be taken, as the instrument is being inserted, to fix and steady 
the head by abdominal pressure, since it is generally far above the 
brim and would readily recede; if this precaution were neglected, 
When the blades are in situ, we proceed to crush by turning the screw 
slowly, and as the blades are approximated the bones yield and the 
cephalotribe sinks into the cranium. The crushed portion then meas- 
ures, of course, no more than the thickness of the blades, that is, about 



522 



OBSTETRIC OPERATIONS 



Fig. 187. 



one and one-half inches. This is necessarily accompanied by some 
bulging of the part of the cranium that is not within the grasp of the 

instrument (Fig. 187), but in slight de- 
formity this is of no consequence and we 
may proceed to extraction, waiting, if pos- 
sible, for a pain, and drawing at first down- 
ward in the axis of the pelvic inlet, as in 
forceps delivery, then in the axis of the 
outlet. The site of perforation should be 
examined to see that no spiculse of bone are 
projecting from it, and if so they should 
be carefully removed. In such cases the 
head often descends at once, and with the 
greatest ease. Should it not do so, or 
should the obstruction be considerable, a 
quarter turn should be given to the handles 
of the instrument, so as to bring the crushed 
portion into the narrower diameter and 
the uncrushed portion into the wider trans- 
verse diameter. It may now be advisable 
to remove the blades carefully, and to re- 
introduce them with the same precautions 
so as to crush the unbroken portion of the 
skull. This adds materially to the diffi- 
culties of the case, since the blades have a 
tendency to fall into the deep channel 
already made in the cranium, and so it is 
by no means always easy to seize the skull 
in a new direction. Before reapplying 
them, if the condition of the patient be 
good and pains be present, it may be well 
to wait an hour or more, in the hope of the 
head being moulded and pushed down into 
the pelvic cavity. This was the plan adopted by Dubois, and, accord- 
ing to Tarnier, was the secret of his great success in the operation. 
Pajofs method of repeated crushings, in the greater degrees of contrac- 
tion, is based on the same idea, and he recommends that the instrument 
should be introduced at intervals of two, three, or four hours, accord- 
ing to the state of the patient, until the head is thoroughly crushed ; 
no attempts at traction being used, and expulsion being left to the 
natural powers. This, he says, should always be done when the con- 
traction is below two and one-half inches, and he maintains that it is 
quite possible to effect delivery by this means when there is only one 
and one-half inches in the antero-posterior diameter. The repeated 
introduction of the blades in this fashion must necessarily be hazard- 
ous, except in the hands of a very skilful operator ; and I believe that 
if a second application fail to overcome the difficulty, which will only 
be very exceptionally the case, it would be better to resort to the meas- 
ures presently to be described. 




Foetal head crushed by the 
cephalotribe. 



OPERATIONS INVOLVING DESTRUCTION OF FGETUS. 523 



Fig. 188. 



Prof. Alex. E. Simpson, of Edinburgh, 1 has suggested the use of an 
instrument which he calls a " basilyst." Its object is to break up the 
base of the foetal skull from within, after the method 
originally proposed by Guyon. The screw-like portion 
of the instrument (Fig. 188), which is inserted through 
the perforation made in the cranial vault, is driven 
through the hard base, which is then disintegrated by 
the separate movable blade. If experience proves that 
this instrument can be readily worked, it promises to be 
a valuable addition to our armamentarium, since it will 
effectually destroy the most resistant portion of the skull, 
without risk of injury to the maternal structures, and 
thus very materially facilitate extraction. 

Extraction by the Craniotomy Forceps. — Should 
we elect to trust to the craniotomy forceps for extraction, 
one blade is to be introduced through the perforation, and 
the other, placed in opposition to it, on the outside of the 
scalp. In moderate deformities, traction applied during 
the pains may of itself suffice to bring down the head. 
Should the obstruction be too great to admit of this, it is 
necessary to break down and remove the vault of the Prof 
cranium. For this purpose Simpson's cranioclast answers son's basiiyst. 
better than any other instrument. One of the blades is 
passed within the cranium, the other, if possible, between the scalp 
and the skull, and the portion of bone grasped between them is broken 
off; this can generally be accomplished by a twisting motion of the 
wrist, without using much force. The separated portion of bone is 
then extracted, the greatest care being taken to guard the maternal 
structures, during its removal, by the fingers of the left hand. The 
instrument is then applied to a fresh part of the skull, and the same 
process repeated until as much of the vault of the cranium as may be 
necessary is broken up and removed. 

Dr. Braxton Hicks 2 has conclusively shown that in difficult cases, 
after the removal of the cranial vault, the proper procedure is to bring 
down the face, since the smallest measurement of the skull after the 
removal of the upper part of the cranium is from the orbital ridge to 
the alveolar edge of the superior maxillary bone. This alteration in 
the presentation he proposes to effect by a small blunt hook made 
for the purpose, which is forced into the orbit, by means of whicli the 
face is made to descend. Barnes recommends that this should be done 
by fixing the craniotomy forceps over the forehead and face, and 
making traction in a backward direction, so as to get the face past the 
projecting promontory of the sacrum. The importance of bringing 
down the face was long ago pointed out by Burns, but it had been lost 
sight of until Hicks again drew attention to it in the paper referred 
to. In the class of cases in which this procedure is valuable, the risk 
to the maternal passages, from the removal of the fractured portions 
of bone, must always be considerable, and it is of great importance 



i Edin. Med. Journ., vol. 1879-80 p. 865. 



2 Obst. Trans., vol. vii. p. 57. 



524 OBSTETRIC OPERATIONS. 

not only to preserve the scalp as entire as possible, so as to protect 
them, but to use the utmost possible care in removing the broken 
pieces of bone. 

Extraction of the Body. — When the extraction of the head has 
been effected, either by the cephalotribe or the craniotomy forceps, 
there is seldom much difficulty with the body. By traction on the 
head one of the axilla? can easily be brought within reach, and if the 
body does not readily pass, the blunt hook should be introduced and 
traction made until the shoulder is delivered. The same can then be 
done with the other arm. If there be still difficulty, the cephalotribe 
may be used to crush the thorax. The body is, however, so com- 
pressible that this is rarely required. 

Embryotomy. — There only remains for us to consider the second 
class of destructive operations. These may be necessary in long-neg- 
lected cases of arm presentation, in which turning is found to be imprac- 
ticable. Here, fortunately, the question of killing the foetus does not 
arise, since it will, almost necessarily, have already perished from the 
continuous pressure. We have two operations to select from, decapita- 
tion and evisceration. 

The former of these is an operation of great antiquity, having been 
fully described by Celsus. It consists in severing the neck, so as to 
separate the head from the body ; the body is then withdrawn by 
means of the protruded arm, leaving the head in utero to be subse- 
quently dealt with. If the neck can be reached without great difficulty 
— and, in the majority of cases, the shoulder is sufficiently pressed clown 
into the pelvis to render this quite possible — there can be no doubt that 
it is much the simpler and safer operation. 

The whole question rests on the possibility of dividing the neck. 
For this purpose many instruments have been invented. The one 
generally recommended in this country is known as Ramsbotham's 
hook, and consists of a sharply curved hook with an internal cutting 
edge. This is guided over the neck, which is divided by a sawing 
motion. There is often considerable difficulty in placing the instru- 
ment over the neck, although, if this were done, it would doubtless 
answer well. Others have invented instruments, based on the principle 
of the apparatus for plugging the nostrils, by means of which a spring 
is passed round the neck, and to the extremity of the spring a short 
cord, or the chain of an 6craseur, is attached ; the spring is then with- 
drawn and brings the chain or cord into position. The objection to 
any of these apparatus is, that they are unlikely to be at hand when 
required, for few practitioners provide themselves with costly instru- 
ments which they may never require. It is of importance, therefore, 
that we should have at our command some means of dividing the neck 
which are available in the absence of any of these contrivances. 
Dubois recommended for this purpose a strong pair of blunt scissors. 
The neck is brought as low as possible by traction on the prolapsed 
arm, and the blades of the scissors guided carefully up to it. By a 
series of cautious snipping movements it is then completely divided 
from below upward. This, if the neck be readily within reach, can 



OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 525 

generally be effected without any particular difficulty. Dr. Kidd, of 
Dublin, 1 who strongly advocated this operation, recommended that an 
ordinary male elastic catheter, strongly curved and mounted on a firm 
stilet, or, still better, on a uterine sound, should be passed round the 
neck. Previous to introduction a cord should be passed through the 
eye of the catheter, which is left round the neck when it is withdrawn. 
By means of this cord a strong piece of whipcord, or the wire of an 
ecraseur, can easily be drawn round the neck and used for dividing it. 
The former, to protect the maternal structures, may be worked through 
a speculum, and by a series of lateral movements the neck is easily 
severed. The ecraseur, however, offers special advantage, since it 
entirely does away with any risk of injuring the mother. 

"Withdrawal of the Body and Delivery of the Head. — After the 
neck is divided the remainder of the operation is easy. The body is 
withdrawn without difficulty by the arm, and we then proceed to 
deliver the head. By abdominal pressure, this, in most cases, can be 
pushed down into the pelvis, so as to come easily within reach of the 
cephalotribe, which is by far the best instrument for extraction. Pre- 
liminary perforation is not necessary, since the brain can escape through 
the severed vertebral caual. The secret of doing this easily is to fix 
aud press down the head sufficiently from above, otherwise it would 
slip away from the grasp of the instrument. The perforator and crani- 
otomy forceps may be used if the cephalotribe be not at hand. Per- 
foration is, however, by no means always easy, on account of the 
mobility of the head. After it is accomplished, one blade of the crani- 
otomy forceps is passed within the skull, the other externally, and the 
head slowly drawn down. 

Evisceration. — The alternative operation of evisceration is a much 
more troublesome and tedious procedure, and should only be used when 
the neck is inaccessible. The first step is to perforate the thorax at its 
most depending part, and to make as wide an opening into it as possi- 
ble, in order to gain access to its contents. Through this the thoracic 
viscera are removed piecemeal, being first broken up as much as possi- 
ble by the perforator, and then, the diaphragm being penetrated, those 
in the abdomen. The object is to allow the body to collapse and the 
pelvic extremities to descend, as in spontaneous evolution. This can 
be much facilitated by dividing the spinal column with a strong pair 
of scissors introduced into the opening made in the thorax, so that the 
body may be doubled up as on a hinge. Here the crotchet may find 
a useful application, for it can be passed through the abdominal cavity 
and fixed on some point in the interior of the child's pelvis, and thus 
strong traction can be made without any risk of injury to the mother. 
It can be readily understood that this process is so lengthy and difficult 
as to render it probably the most trying of obstetric operations; it is 
certainly inferior in every respect to decapitation, and is only to be 
resorted to when that is impracticable. 2 

1 Dublin Quart. Journ. of Med. Science, vol. li. p. • 

- In nine cases of impaction of the foetus in a transverse position, in the T mtcd states, the 
Cesarean operation has been performed, owing to great difficulty in accomplishing either decapi- 
tation or evisceration, and six of the women were saved. The three deaths were from exhaustion. 
— Harris's note to third American edition. 



526 OBSTETRIC OPERATIONS. 



CHAPTEE VI. 

THE CESAREAN SECTION— PORRO'S OPERATION. 

History of the Csesarean Section. — The Csesarean section has per- 
haps given rise to more discussion than any other subject counected with 
midwifery, and there is yet much difference of opinion as to the limits of, 
and indications for, the operation. The period at which the Csesarean 
section was first resorted to is not known with accuracy. It seems to 
have been practised by the Greeks, after the death of the mother ; and 
Pliny mentions that Scipio Africanus and Manlius were born in this 
way. The name of Caesar is said to have been given to children so 
extracted, and afterward to have been assumed as a family patronymic. 
These children were dedicated to Apollo, whence arose the practice of 
things sacred to that god being taken under the special protection of 
the family of the Caesars. Many celebrities have been supposed to 
owe their lives to the operation, among the rest Aesculapius, Julius 
Caesar, and Edward VI. of England. Regarding the two latter, there 
is conclusive proof that the tradition is without foundation. There is 
no doubt that the operation was constantly practised on women who 
had died at an advanced period of pregnancy, and indeed it has, at 
various times, been enforced by law. Thus, among the Romans it 
was decreed by Numa that no pregnant woman should be buried until 
the foetus had been removed by abdominal section. The Italian laws 
also made it necessary, and the operation has always received the 
strong support of the Roman Church. So lately as the middle of the 
eighteenth century the King of Sicily sentenced to death a physician 
who had neglected to practise it. The first authentic case in which the 
operation was performed on a living woman occurred in 1491. It 
was afterward practised by Nufer in 1500; and in 1581 Rousset pub- 
lished a work on the subject in which a number of successful cases were 
related. In English works of that time it is not alluded to, although 
it was undoubtedly performed on the Continent, and to such an extent 
that its abuse became almost proverbial. We have evidence in Shakes- 
peare, however, that the operation was familiarly known in Great 
Britain, since he tells us that — 

. . . Macduff was from his mother's womb 
Untimely ripped. 

Pare* and Guillemeau, amongst the writers of the period, were noted 
for their hostility to the operation, while others equally strongly up- 
held it. 

In England it has, until recently, scarcely ever been performed in a 
manner which offers even the faintest hope of success. It has been 
looked upon as almost necessarily fatal to the mother, and it has, there- 



CESAREAN SECTION. 527 

fore, been delayed until the patient has arrived at the utmost stage of 
exhaustion. For example, in looking over the records of British cases, 
it is no uncommon thing to find that the Cesarean section was resorted 
to two, three, or even six days after labor had begun, and when the 
patient was almost moribund. With rare exceptions within the last 
few years, the operation has been performed in what may be called a 
hap-hazard way. In many cases long and fruitless attempts at delivery 
by craniotomy had already been made, so that the passages had been 
subjected to much contusion and violence. Little or no attempt has 
been made to obviate the well-known risks of abdominal operations ; 
no care has been taken to prevent blood and other fluids finding their 
way into the peritoneal cavity, and no means have been adopted subse- 
quently to remove them. It is, therefore, not so much a matter of 
surprise that the mortality has been so great, but rather that auy cases 
have recovered. 

From what we know of the history of ovariotomy, its early fatality, 
and the extreme and even apparently exaggerated precautions which 
are essential to its success, it is fair to conclude that, if the Cesarean 
section were performed, as it is to be hoped it always be in future, 
with the same careful attention to minute details as ovariotomy, the 
results would not be so disastrous. Making every allowance for these 
facts, it must be admitted that the Cesarean section, as hitherto per- 
formed, has been necessarily almost a forlorn hope; although happily 
recent statistics show that this need no longer be considered the case. 
In making these observations I have no intention of contesting the 
well-established rule of British practice that it is not admissible as an 
operation of election, and must only be resorted to when delivery per 
vias nat wales is impossible. 

Statistical Returns are not Reliable. — The mortality, as given in 
statistical returns from various sources, differs so greatly as to make 
them but little reliable. Eadford has tabulated the operations per- 
formed in this country up to 1868, and the list has been completed by 
Harris 1 up to 1879. The cases amount to 138 in all, of which 26 were 
successful. Michaelis and Kayser found that out of 258 cases and 338 
operations, 54 and 64 per cent, respectively were fatal. These include 
operations performed under all sorts of conditions, even when the 
patient was almost moribund ; and until we are in possession of a 
sufficient number of cases performed under conditions showing that 
the result is certainly due to the operation — in which is was undertaken 
at an early period of labor and performed with a reasonable amount 
of care — it is obviously impossible to arrive at any reliable conclusions 
as to the mortality of the operation. That it is necessarily hopeless 
is certainly not the case, and we know that on the Continent, where it 
is resorted to much oftener and earlier in labor than in England, there 
are authentic cases in which it has been performed twice, thrice, and 
even, in one instance, four times on the same patient. Kayser thought 
that a second operation on the same patient afforded a better prognosis 
than at first, probably because peritoneal adhesions, resulting from the 
first operation, have shut off the general abdominal cavity from the 

i "The Csesarean Operation in the United Kingdom." Brit. Med. Journ., vol., p. 508. 



528 OBSTETRIC OPERATIONS. 

uterine wound ; and he believed that in second operations the mortality 
is not more than 29 per cent. 

The Csesarean Section in America. — The Csesarean section has 
been much more successful in America than in Great Britain. Dr. 
Harris, of Philadelphia, who has paid much attention to the subject, 
has collected 134 cases occurring in the United States, of which 53, or 
about 40 per cent., were successful as regards the mother. These 
favorable results he refers partly to the fact that none of the American 
cases were the subjects of mollities ossium, rhachitic patients forming 
one-half of the entire number, partly to the prevalence of habits of 
beer- and gin-drinking in this country. He also gives some interesting 
facts showing how remarkably the mortality of the operation was 
lessened when performed soon and the patient is not exhausted by 
lono; and fruitless labor. Out of 27 selected cases of this kind, 20, or 
1^-j per cent., were successful. The latest European statistics show 
that the modifications of the operation now universally adopted upon 
the Continent of Europe are followed by the most gratifying results. 
Thus, out of 22 recent operations, 18 mothers recovered. 

Results to the Child. — The mortality of the children likewise can- 
not be ascertained from statistical returns, since, in the large majority 
of cases in which dead children were extracted, the result had nothing 
to do with the operation. Indeed, there is nothing in the operation 
itself which can reasonably be supposed to affect the child. If, there- 
fore, the child be alive when the operation is commenced, there is 
every probability of its being extracted alive ; and Radford's conclu- 
sion, that " the risks to infants in Cesarean births is not much greater 
than that which is contingent on natural labor, provided correct prin- 
ciples of practice are adopted," probably very nearly represents the 
truth. 

Causes Requiring' the Operation. — The Cesarean section is re- 
quired when there is such defective proportion between the child and 
the maternal passages that even a mutilated foetus cannot be extracted. 
This in by far the greatest number of cases is due to deformity of the 
pelvis arising from rickets or mollities ossium. The latter may occur 
in a patient who has been previously healthy, and who has given birth 
to living children. It is a more common cause of the extreme varieties 
of deformity than rickets ; and out of 77 British cases tabulated by 
Radford, in 43 the deformity was produced by osteomalacia, and in 14 
by rickets. In certain cases the pelvis itself may be of normal size, 
but has its cavity obstructed by a solid tumor of the ovary, of the 
uterus itself, or one growing from the pelvic wall. The obstruction 
may also depend on morbid conditions of the maternal soft parts, of 
which the most common is advanced malignant disease of the cervix. 
Other conditions may, however, render the operation essential. Thus 
Dr. Newman 1 recorded a case in which he performed it for insurmount- 
able resistance and obstruction of the cervix, which was believed at the 
time to be caused by malignant disease. The patient recovered, and 
was subsequently delivered naturally, and without anything abnormal 

1 Obst. Trans., vol. vii, p. 343. 



CESAREAN SECTION. 529 

being made out. This renders it probable that the disease was not 
malignant, and it may possibly have been an extensive inflammatory 
exudation into the tissues of the cervix, subsequently absorbed. I 
myself was present at a Cesarean section performed in Calcutta in the 
year 1857, when the pelvis was so uniformly blocked up with exuda- 
tion, probably due to extensive pelvic cellulitis or hematocele, that the 
operation was essential. 

Limits of Obstruction Justifying- the Operation. — Different 
accoucheurs have iixed on various limits for the operation. Most 
British authorities are of opinion that it need not be resorted to if the 
smallest diameter of the pelvis exceed one and a half inches. 1 This 
question has already been considered in discussing craniotomy, and it 
has been shown that a mutilated foetus may be drawn through a pelvis 
of one and a half inches antero-posterior diameter, provided there be a 
space of three inches in the transverse diameter. If sufficient space for 
using the necessary instruments does not exist, the Cesarean section 
may be required, even when there is a larger antero-posterior diameter 
than one and a half inches. This is especially likely to occur when 
we have to do with deformity arising from mollities ossium, in which 
the obstruction is in the sides and outlet of the pelvis, the true con- 
jugate being sometimes even elongated. On the Continent the Cesarean 
section is constantly practised as an operation of election when the 
smallest diameter measures from two to two and a half inches ; and 
when the child is known to be alive, some foreign authors recommend 
it when there is as much as three inches in the antero-posterior diameter. 
In Great Britain, where the life of the child is most properly con- 
sidered of secondary importance to the safety of the mother, Ave cannot 
fix one limit for the operation when the child is living, and another 
Avhen it is dead. Xor, I think, can we admit the desire of the mother 
to run the risk, rather than sacrifice the child, as a justification of the 
operation, although this is laid down as an indication by Schroeder. 2 
Great as are the dangers attending craniotomy in extreme deformity, 
there can be no doubt that we must perform it whenever it is prac- 
ticable, and only resort to the Cesarean section when no other means 
of delivery are possible. 

For this reason I think it unnecessary to discuss the question 
whether we are justified in destroying the foetus in several successive 
pregnancies, when the mother knows that it is impossible for her to 
give birth to a living child. Denman was the first to question the 
advisability of repeating craniotomy on the same patient. Amongst 
modern authors .Radford took the most decided view on this point, 
and distinctly taught that even when delivery by craniotomy is 
possible, it "can be justified on no principle, and is only sanctioned 
by the dogma of the schools, or by usage," and that, therefore, the 
Cesarean section should be performed with the view of saving the 
child. Doubtless much can be said from this point of view; but, 
nevertheless, he would be a bold man who would deliberately elect 

1 In Dr. Parry's table of 70 craniotomies, there are 34 cases of two to two and a half inches 
conjugate. 
* Manual of Midwifery, p. 202. 

34 



530 OBSTETRIC OPERATIONS. 

to perform the Cesarean section on such grounds. 1 It is to be 
hoped, however, that in these days the induction of premature labor 
or abortion would always spare us the necessity of deciding so delicate 
a point. 

Post-mortem Csesarean Operation. — The Cesarean section may 
also be required in cases in which death has occurred during pregnancy 
or labor. This was the indication for which it was first employed, and 
it has constantly been performed when a pregnant woman has died at 
an advanced period of utero-gestation. There is no doubt that a 
prompt extraction of the child under these circumstances has fre- 
quently been the means of saving its life, but by no means so often as 
is generally supposed. Thus, Schwarz 2 showed that out of 107 cases 
not one living child was extracted. Duer 3 has written an interesting 
paper on this subject, in which he has tabulated 55 cases of post-mortem 
Cesarean sections. In 40 a living child was extracted, the time elapsing 
after the death of the mother being as follows : " Between one and five 
minutes, including i immediately ; and ' in a few minutes/ there were 
21 cases ; between five and ten minutes, none ; between ten and fifteen 
minutes, 13 cases ; between fifteen and twenty-three minutes, 2 cases ; 
after one hour, 2 cases ; and after two hours, 2 cases." In those ex- 
tracted, however, after the lapse of an hour, the children did not ulti- 
mately survive, and the cases themselves seem open to some doubt. 

Want of Success in Post-mortem Operation. — The reason that 
the want of success has been so great is doubtless the delay that must 
necessarily occur before the operation is resorted to ; for, independently 
of the fact that the practitioner is seldom at hand at the moment of 
death, the very time necessary to assure ourselves that life is actually 
extinct will generally be sufficient to cause the death of the foetus. 
Considering the intimate relations between the mother and child, we 
can scarcely expect vitality to remain in the latter more than a quarter 
or, at the outside, half an hour after it has ceased in the former. The 
recorded instances in which a living child was extracted ten, twelve, 
and even forty hours after death, were most probably cases in which 
the mother fell into a prolonged trance or swoon, during the con- 
tinuance of which the child must have been removed. A few authentic 
cases, however, are known in which there can be no reasonable doubt 
that the operation was performed successfully several hours after the 
mother was actually dead. 

Since, then, there is a chance, however slight, of saving the child's 
life, we are bound to perform the operation, even when so much time 
has elapsed as to render the chances of success extremely small. It 
might be considered almost superfluous to insist on the necessity of 
assuring ourselves of the mother's death before commencing the neces- 
sary incisions; but, unfortunately, numerous instances are known in 
which mistakes in diagnosis have been made, and in which the first 

1 This was done twice successfully by Prot. William Gibson in the case of Mrs. Reybold, of Phila- 
delphia, in 1835 and 1837, after she had twice been delivered by craniotomy under Prof. Charles D. 
Meigs, who declined destroying any more children for her. Mrs. R. still lives at the age of seventy, 
and the daughter and son likewise, with their six children,— Harris's note to third American 
edition. 

* Monats. f. Geburt., suppl.. 1862, Bd. xviii. S. 112. 

3 " Post-mortem Delivery," Amer. Journ. of Obst., vol. xii. pp. 1 and 374. 



CESAREAN SECTION. 531 

steps of the operation have shown that the mother was still alive. The 
operation should, therefore, always be performed with the same care 
and caution as if the mother were living. If death has occurred 
during labor, some have advised version as a preferable alternative. 
This can only be resorted to, with any hope of success, if the passages 
be in a condition to admit of delivery with rapidity ; otherwise the 
delay occasioned by dilatation, even when forcibly accomplished, and 
the drawing of the child through the pelvis, will be almost necessarily 
fatal. The only argument in favor of version is that it is less painful 
to the friends ; and if they manifest a decided objection to the Cesarean 
section, there can be no reason why an attempt to save the child in 
this way should not be made. 

Causes of Death after Csesarean Section. — The causes of death 
after the Cesarean section may, speaking generally, be classed under 
four principal heads : hemorrhage, peritonitis and metritis, shock, sep- 
ticemia and exhaustion from long delay. These are pretty much the 
same as those following ovariotomy, and the resemblance between the 
two operations is so great that modern experience as to the best mode 
of performing ovariotomy, as well as regards the after-treatment, 
may be taken as a guide in the management of cases of Cesarean 
section. 

Hemorrhage to an alarming extent is a frequent complication, 
though seldom the cause of death. Thus, out of eighty-eight opera- 
tions, the particulars of which have been carefully noted, severe 
hemorrhage occurred in fourteen, six of which terminated successfully, 
and in four only could the fatal result be ascribed to the loss of blood. 
In one of these the source of the hemorrhage is not mentioned, in 
another it came from the wound in the abdominal wall, and in the 
other two from the uterine incision being made directly over the pla- 
centa. In neither of the two latter was the loss of blood immediately 
fatal ; for it was checked by uterine contraction, and only recurred 
after many hours had elapsed. The divided uterine sinuses, and the 
open mouths of the vessels at the placental site, are the most common 
sources of hemorrhage. 

Much may be done to diminish the risk of bleeding, but even with 
every precaution it must be a source of danger. Hemorrhage from 
the abdominal wall may be best prevented by making the incision as 
nearly as possible in the line of the linea alba, so as not to wound the 
epigastric arteries, and by controlling bleeding by pressure forceps as 
we proceed, as is done in ovariotomy. The principal loss of blood 
will be met with in dividing the uterus ; and this will be the greatest 
when the incision is near or over the placental site, where the largest 
vessels are met with. AVe are recommended to ascertain the position 
of the placenta by auscultation, and thus, if possible, to avoid opening 
the uterus near its insertion. But even if we admit the placental 
souffle to be a guide to its situation, if the placenta be attached to the 
anterior walls of the uterus, a knowledge of its position would not 
always enable us to avoid opening the uterus in its immediate vicinity. 
We must, in the event of its lying under the incision, rather hope to 
control the hemorrhage by removing it at once from its attachments, 



532 OBSTETRIC OPERATIONS. 

and rapidly emptying the uterus. When the child has been removed 
there may be a large escape of blood ; but this will generally be stopped 
by the contraction of the uterus, in the same manner as after natural 
labor. Should contraction not take place, the uterus may be firmly 
grasped for the purpose of exciting it. This plan was advocated by 
the late Ludwig Winckel, who had a large experience in the operation ; 
and by using free compression in this way, and making a point of not 
closing the wound until the uterus was firmly contracted, he had never 
met with any inconvenience from hemorrhage. Sanger, to whose writ- 
ings we owe so much in perfecting the modern Csesarean section, relies 
much on frequent kneading of the uterus during the application of the 
sutures. Murdoch Cameron, of Glasgow, 1 who has had the largest 
experience of the operation amongst British operators, recommends that 
the cut surfaces of the uterus should be firmly pressed together. He 
also places a soft-rubber ring pessary on the uterus before commencing 
the incision, which is made within the circle, and by this means, he 
says, the chance of hemorrhage is lessened. If bleeding continue, 
styptic applications may be used, as in a case reported by Hicks, who 
was obliged to swab out the uterine cavity with a solution of per- 
chloride of iron. The method first used by Muller, and. now adopted 
by most operators, of placing a soft-rubber cord around the uterus, 
will tend effectually to control hemorrhage, but Cameron objects to it 
as likely to induce inertia after its removal. This, however, is not the 
experience of most operators who have used it, and I think that this 
plan should be adopted. The cord should be slipped over the fundus 
and behind the uterus before it is incised, and then either tied or 
clamped with pressure forceps after it is put on the stretch. By thus 
temporarily controlling the uterine circulation we are enabled to com- 
plete the operation without undue haste. 

Among the most frequent causes of death are peritonitis and metritis. 
Kayser attributed the fatal results to them in 77 out of 123 unsuccess- 
ful cases. 

The mere division of the peritoneum will not account for the fre- 
quency of this complication, since its occurrence is considerably more 
frequent than after ovariotomy, in which the injury to the peritoneum 
is quite as great — and indeed greater, if we take into account the 
adhesions which have to be divided or torn in that operation. 

The division of the uterus must be regarded as one source of this 
danger. Dr. West lays great stress on its unfavorable condition after 
delivery for reparative action. He believes that the process of invo- 
lution or fatty degeneration which commences in the muscular fibres 
previous to delivery, renders them peculiarly unfitted to cicatrize ; and 
he points out that, on post-mortem examination, the edges of the 
incision have been found dry, of unhealthy color, gaping, and showing 
no tendency to heal. On this account Hicks and others have operated 
ten days or more before the full period of labor, in the hope that the 
risk from this source might be avoided. It is by no means certain, 
however, that the change in the uterine fibres is the cause of the wound 

i Brit. Med. Journ., March 7, 1889. 



CESAREAN SECTION. 533 

not healing, and involution will commence at once when the uterus is 
emptied, even if the full period of pregnancy have not arrived. As a 
point of ethics, moreover, it is questionable if we are justified in antici- 
pating the date of so dangerous an operation, even by a few weeks, 
unless the benefit to be derived is very decided indeed. 

One important cause of peritonitis is the escape of the lochia through 
the uterine incision into the cavity of the peritoneum, which there 
decompose and act as an unfailing source of irritation. This may be 
prevented, to a great extent, by seeing that the os uteri is patulous, so 
as to afford a channel for the escape of discharges, and by effective 
closing of the uterine wound by sutures. In addition, there is the 
danger arising from blood aud liquor amnii escaping into the peri- 
toneum, and subsequently decomposing. There is little evidence that 
" la toilette du peritoine," on which ovariotomists now lay so much 
stress, has ever been particularly attended to in Cesarean opera- 
tions. 

The chief predisposing cause of these inflammations, however, must 
be looked for in the condition of the patient, just as asthenic inflam- 
mation in ovariotomy is most frequently met with in those whose 
general health is broken down by the long continuance of the disease. 
We are fully justified, therefore, in assuming that peritonitis and 
metritis will be more likely to occur after the Cesarean section when 
that operation has been unnecessarily delayed, and when the patient 
is exhausted by a protracted labor. In proof of this we find that, in 
a large proportion of the cases above mentioned, peritonitis occurred 
when the operation was performed under unfavorable conditions. 

The sources of septicaemia are abundantly evident ; not the least, 
probably, being absorption by the open vessels in the uterine incision. 

The last great danger is general shock to the nervous system. In 
Kayser's 123 cases, 30 of the deaths are referred to this cause. In 
the large majority of these the patient was profoundly exhausted 
before the operation was begun. It is in predisposing to these nervous 
complications that we should, a priori, expect that vacillation and 
delay would be most hurtful ; and in operating when the patient's 
strength is still unimpaired, we afford her the best chance of bearing 
the inevitable shock of an operation of such magnitude. 

In addition, a few cases have been lost from accidental complications, 
which are liable to occur after any serious operation, and which do not 
necessarily depend on the nature of the procedure. 

There is only one source of danger special to the child which is 
worthy of attention. As the infant is being removed from the cavity 
of the uterus, the muscular parietes sometimes contract witli great 
rapidity and force, so as to seize and retain some part of its body. 
This occurred in two of Dr. Radford's cases, and in one of them it is 
stated that ■ " the child was vigorously alive when first taken hold of, 
but, from the length of time occupied in extracting the head, it became 
so enfeebled as to show only slight signs of life," and subsequently all 
attempts at resuscitation failed. I have myself seen the head caught 
in this way, and so forcibly retained that a second incision was re- 
quired to release it. In Dr. Radford's cases the placenta happened to 



531 OBSTETRIC OPERATIONS. 

be immediately under the incision, and he attributes the inordinate 
and rapid contraction of the uterus to its premature separation. It is 
difficult to believe that this was more than a coincidence, because the 
contraction does not take place until the greater part of the child's 
body has been withdrawn, and because numerous cases are recorded in 
which the uterus was opened directly over the placenta, or in which 
it was lying loose and detached, in none of which this accident occurred. 
The true explanation may, I think, be found in the varying irritability 
of the uterus in different cases. 

Irrespective of the risk of portions of the child being caught and 
detained, rapid contraction is a distinct advantage, since the danger of 
hemorrhage is thereby thus diminished. Serious consequences may be 
best avoided by removing, when practicable, the head and shoulders 
of the child first, or by employing both hands in extraction, one being 
placed near the head, the other seizing the feet. Either of these 
methods is preferable to the common practice of laying hold of the 
part that may chance to lie most conveniently near the line of incision. 
If this point were properly attended to, although the detention of the 
lower extremities might occasionally occur, the life of the child would 
not be imperilled. 

The Patient should be Prepared for the Operation. — The 
preparation of the patient for the operation should seriously occupy 
the attention of the practitioner, and this is the more essential since 
almost all patients requiring the Csesarean section are in a wretchedly 
debilitated condition. If the patient be not seen until she is actually 
in labor, of course this is out of the question. But this will rarely be 
the case, since the deformed condition of the patient must generally 
have attracted attention. Every possible means should be taken, 
therefore, when practicable, to improve the general health by abun- 
dance of simple and nourishing diet, plenty of fresh air, and suitable 
tonics (amongst which preparations of iron should occupy a prominent 
place), while the state of the secretions, the bowels, skin, and kidneys, 
should be specially attended to. Whenever it is possible a large, airy 
apartment should be selected for the operation. These details may 
seem trivial and unnecessary; but to insure success in so hazardous an 
undertaking no care can be considered superfluous, and probably the 
want of attention to such points has had much to do with increasing 
the mortality. 

The question arises whether we should operate before labor has com- 
menced. By selecting our own time we certainly have the advantage 
of operating under the most favorable conditions, instead of possibly 
hurriedly. Every preparation can be made leisurely and completely; 
we can insure complete sterilization of instruments, sutures, etc., in a 
way which might be impossible when the date of the operation is left 
uncertain ; and we can avoid any possible chance of having to operate 
by artificial light. Waiting until labor commences is preferred by some 
operators because of its insuring the partial opening of the os uteri so 
as to afford a channel of escape for the lochia, and the certainty of 
active contraction of the uterus to avert hemorrhage. Cases will arise 
when we are called to a patient actually in labor, when we have no 



CESAREAN SECTION. 535 

choice in the matter; but personally, whenever it is practicable, I 
should prefer to select my own time, as near as possible to her expected 
date of delivery. 

The Administration of Ansestketics. — The operation itself is 
simple. The patient should be placed on a table, in a good light, and 
with the temperature of the room raised to about 65°. Chloroform 
has so frequently been followed by severe vomiting that it is probably 
better not to administer it. For the same reason Sir Spencer Wells 
gave up using it in ovariotomy, and found that chloro-methyl an- 
swered admirably ; ether, or the A. C. E. mixture, is also devoid of 
the disadvantages of chloroform. 

To insure as great a measure of success as possible, the operation 
should be performed with all the minute precautions used in ovari- 
otomy. 

Description of the Operation. — The incision should be made as 
much as possible in the line of the linea alba. On account of the 
deformity, the configuration of the abdomen is often much altered, and 
some have advised that the incision should be made oblique or trans- 
verse, and on the most prominent part of the abdomen. The risk of 
hemorrhage being thus much increased, the practice is not to be recom- 
mended. The skin and muscular fibres are carefully divided, layer by 
layer, until the shining surface of the peritoneum is reached, and any 
bleeding vessels should be secured with pressure forceps as we proceed. 
A small opening is now made in the peritoneum, which should be laid 
open along the whole length of the incision, upon two fingers of the 
left hand introduced as a guide. One or two silk sutures should now 
be passed through the upper end of the incision. The object of these 
is to temporarily close the abdominal parietes after the uterus is opened, 
so as to prevent the escape of the intestines, or the entrance of blood, 
etc., into the peritoneal cavity. The rubber cord should now be placed 
in situ, as already advised. Before incising the uterus an assistant 
should carefully support it in a proper position, and push it forward 
by the hands placed on either side of the incision, so as to bring its 
surface into apposition with the external wound, and prevent the escape 
of the intestines, and towels wrung out of a hot aseptic lotion should be 
placed on either side, between the uterus and the abdominal parietes, 
to prevent blood and liquor amnii entering the abdomen ; otherwise 
the line of incision should be as nearly as possible central. The sub- 
stance of the uterus is next divided until the membranes are reached, 
which are punctured and divided in the same way as the peritoneum. 
It is important not to puncture these until the uterine incision is com- 
pleted, and we are ready to remove the child. The uterine incision 
should be of the same length as that in the abdomen, and it should not 
be made too near the fundus ; for not only is that part more vascular 
than the body of the uterus, but wounds in that situation are more apt 
to gape, and do not cicatrize so favorably. After the uterus is opened, 
Dr. Ludwig AVinckel has recommended that the fingers of an assistant 
should be placed in the two terminal angles of the wound, so that the 
ends of the incision may be hooked up and brought into close apposi- 
tion with the abdominal opening. By this means he prevented not 



536 OBSTETRIC OPERATIONS. 

only the escape of blood and liquor amnii into the cavity of the peri- 
toneum, but also the protrusion of the abdominal viscera. 

Removal of the Child. — We now divide the membranes and care- 
fully remove the child, the head and shoulders being taken out (if pos- 
sible) first ; the placenta and membranes are afterward extracted. The 
assistant who is holding the uterus in contact with the abdominal 
parietes can, at this time, press it out of the incision as it contracts on 
the removal of the child. Should the placenta be unfortunately found 
immediately under the incision, a considerable loss of blood is likely 
to take place, which can only be checked by removing it from its 
attachments and concluding the operation as rapidly as possible. 

Eventration of the Uterus. — As soon as the child is removed, the 
uterus should be turned out of the abdominal cavity, which is tempo- 
rarily closed by the sutures already introduced, and further protected 
by placing a large flat sponge behind the uterus. At the same time 
hemorrhage is controlled by a rubber cord tied round the cervix. This 
gives time thoroughly to attend to the suturing of the uterine incision, 
a point of great importance. The uterus should now be surrounded by 
soft napkins wrung out of warm 1 : 2000 perchloride of mercury solu- 
tion. After the placenta has been removed and the hemorrhage arrested 
we should see that the os uteri is open, so that any fluid in the uterine 
cavity may drain into the vagina. The cavity should also be swabbed 
out with tincture of iodine or dusted with iodoform. 

Importance of Securing" Uterine Contraction. — As soon as the 
child and the secundines have been extracted, the sooner the uterus 
contracts the better. It will usually do so of itself, but should it 
remain lax and flabby, it should be pressed and stimulated by the 
hand. We are specially warned against handling the uterus by Rams- 
botham and others ; but there seems no valid reason why we should not 
restrain hemorrhage in this way, as after a natural labor. The inter- 
vention of the abdominal parietes, in their lax condition after delivery, 
can make very little difference between the two cases. Ergotine 
administered hypodermically will also be useful in promoting efficient 
contraction. 

Ligature of the Fallopian Tubes. — In some recent cases the 
Fallopian tubes have been ligatured and divided at the time of the 
operation, with the view of preventing future impregnation, or it may 
be preferable to remove the uterine appendages altogether. This does 
not sensibly increase its risk, and seems to be a judicious precaution in 
any case in which the pelvis is much deformed. 

Closure of the Uterine Wound. — Much of the recent success in 
this operation is due to the careful closing of the uterine incision by 
sutures. Sanger, who has paid great attention to this point, used for- 
merly to strip off the peritoneum for about five millimetres on each 
side of the incision, and then resect the muscular wall for about two 
millimetres ; this, however, he has now given up. He inserts eight 
to ten deep sutures of silk through the peritoneum and muscle, but not 
through the mucosa, taking care to turn in the parietal edges so as to 
bring them into accurate contact, with the view of securing rapid adhe- 
sion. The reason for not passing the sutures into the uterine cavity is 



CESAREAN SECTION. 537 

to prevent the possibility of septic material finding its way along the 
track of the sutures into the peritoneum. Finally he passes twenty to 
twenty-five fine silk sutures through the inverted edges of the perito- 
neum. Cameron uses only seven to twelve deep stitches of silk, and 
reserves superficial sutures, for which he uses gut, for any points where 
it might be thought advisable to insert them. The best way of closing 
the uterine wound is, I think, that recommended by Dudley, 1 who 
uses a continuous buried suture of catgut, or two if necessary, extend- 
ing the whole length of the incision, completed by a superficial contin- 
uous suture of the peritoneum. I should myself prefer fine Chinese 
silk, which I employ in all abdominal sections on account of the 
thoroughness with which it can be rendered aseptic by boiling. The 
provisional elastic tubing may now be removed, and the uterus replaced 
in the abdominal cavity. 

A point of great importance, and not sufficiently insisted on, is the 
advisability of not closing the abdominal wound until we are thoroughly 
satisfied that hemorrhage is completely stopped, since any escape of 
blood into the peritoneum would very materially lessen the chances of 
recovery. In a successful case reported by Dr. Newman, 2 the wound 
was not closed for nearly au hour. Before doing so, all blood and 
discharges should be carefully removed from the peritoneal cavity by 
clean soft sponges dipped in warm water. The abdominal wound 
should be closed in layers by continuous sutures of fine silk, first the 
peritoneum, then the muscles and aponeuroses, these being buried, and 
lastly the skin. By this means a firm cicatrix is insured, and the chjiuce 
of hernial protrusion is reduced to a minimum. If, as should be the 
case, the operation is performed with full antiseptic precautions, the 
wound should now be dressed precisely as after ovariotomy. 

Subsequent Management. — Into the subsequent treatment it is 
unnecessary to enter at any length, since it must be regulated by general 
principles, each symptom being met as it arises. It has been customary 
to administer opiates freely after the operation j but they seem to have 
a tendency to produce sickness and vomiting, and ought not to be 
exhibited unless pain or peritonitis indicates that they are required. 
In fact, the treatment should in no way differ from that usual after 
ovariotomy, and the principles that should guide us will be best shown 
by the following quotation from Sir Spencer Wells' description of that 
operation : " The principles of after-treatment are — to obtain extreme 
quiet, comfortable warmth, and apply perfectly clean linen to the 
patient; to relieve pain by warm applications to the abdomen, and by 
opiate enemas; to give stimulants when they are called for by failing 
pulse or other signs of exhaustion ; to relieve sickness by ice, or iced 
drinks; and to allow plain, simple, but nourishing food. The catheter 
must be used every six or eight hours, until the patient can move 
without pain. 

Porro-Caesarean Operation. — An important modification of the 
Csesarean section has been adopted, which is generally known as Porro's 
operation, from Professor Porro, of Pavia, who was the first European 

1 Dudlev. "The Technique of the Csesarean Section." Amer. Journ. of Obstet., January, 1895. 

2 Obst. trans... vol. viii. p. 343. 



538 OBSTETRIC OPERATIONS. 

surgeon who practised it. In this operation, after the uterus is emptied, 
the entire organ is drawn out of the abdominal wouud and excised, its 
neck being first constricted so as to suppress hemorrhage, the stump 
being fixed externally in the manner of the pedicle in ovariotomy. 
The idea is by no means new. It appears to have been first suggested 
by an Italian — Dr. Cavallini— in 1768. In 1823 the late Dr. Blun- 
dell made the same proposal, and fortified it by experiments on preg- 
nant rabbits, in the course of which he found that he lost all by the 
Cesarean section, but saved three out of four in which he ligatured 
and amputated the uterus. The suggestion was not, however, carried 
into actual practice until Dr. Storer, of Boston, in 1869, removed the 
uterus in a case of fibroid tumor obstructing the pelvis and impeding 
delivery. 

Since Porro's first case the operation has been frequently performed 
on the Continent, with results which are, on the whole, encouraging* 
The cases have been carefully tabulated by Dr Harris, of Philadelphia, 
who had collected up to the end of 1889 1 158 cases occurring in the 
previous five years, with 47 deaths, giving a mortality of 29 per cent. 
This is a great improvement on the former figures, when the mortality 
was 50.6 per cent. 2 The obvious advantage of this plan is, that instead 
of leaving the incised uterus, with its possibly gaping wound and all 
the attendant risk of septic mischief, in the abdominal cavity, it is fixed 
externally, and in a position where it can be readily dressed. 

The objection is that it entirely unsexes the patient; but in the class 
of women requiring the Cesarean section from pelvic deformity, it is 
questionable whether this can be fairly considered as a drawback. It 
is perhaps not justifiable to attempt as yet any positive decision as to 
the indications for this plan. It certainly seemed at first to be less 
dangerous than the Caesarean section, but the improved results recently 
obtained in the latter operation have shown how it affords the patient 
as good, if not a better chance, without permanent mutilation, and 
Porro's operation probably requires for its skilful performance a more 
extensive experience in abdominal surgery. "It seems probable, 
therefore, that in future the Porro operation will be chiefly adopted 
when for some reason, such as the existence of fibro-myomata, the 
ablation of the uterus is specially indicated." 

The operation in the successful cases has been performed with full 
antiseptic precautions, and the neck of the uterus, after the organ is 
emptied, carefully secured by ligatures before its body is amputated. 
Some operators have encircled the neck of the uterus with a chain or 
wire 6craseur before removing it, and by this means completely con- 
trolled hemorrhage. The late Dr. Elliot Richardson 3 transfixed the 
neck of the uterus with two large pins crossing each other, before re- 
moving the wire of the 6craseur, and encircled them with stout car- 
bolized cord. Miiller, of Berne, has recommended that the entire 
uterus should be turned out of the abdominal cavity through a long 
incision, before it is emptied, so as to avoid the risk of its fluid con- 

1 Amer. Gyn. Trans., 1891. 

2 See Godson on Porro's operation, Brit. Med. Journ., 1884, and note to 7th ed., vol. ii. p. 243. 
J Amer. Journ. of Med. Sciences, 1881. 



LAPARO-ELYTROTOMY AND SYMPHYSEOTOMY. 539 

tents entering the abdomen; but this manoeuvre has not always proved 
feasible. The pedicle has generally been fixed in the lower angle of 
the abdominal wound and dressed autiseptically. In most cases one 
or more drainage-tubes have been used, either through Douglas's space 
or in the abdominal wound. 

Frank 1 recommends a modification of this operation, in which the 
uterus is amputated through the vagina. After incising the uterus 
and removing the child, he inverts the uterus and applies an elastic 
ligature round it and the ovaries outside the vagina. He now closes 
the abdominal wound, as in ovariotomy, and subsequently amputates 
the uterus below the ligature, separating and sewing the peritoneum 
over the stump. The operation is said to be very simple, and seven 
out of the eight cases he has thus operated on recovered. 2 



CHAPTEE VII. 

LAPARO-ELYTKOTOMY AND SYMPHYSEOTOMY. 

Bearing in mind the great mortality attending the Cesarean section, 
it is not surprising that obstetricians should have anxiously considered 
the possibility of devising substitutes which should afford the mother 
a better chance of recovery. Two proposals of this kind have been 
suggested, and from both great results were anticipated. 

Laparo-elytrotomy. — One of these is the operation of laparo- 
elytrotomy as perfected by Thomas, of New York, in 1870. For some 
years subsequent to that date it attracted considerable attention and 
was frequently performed. The results were on the whole promising : 
out of fourteen cases, seven mothers recovered and nine children were 
born alive ; and there was good reason to expect a still higher success 
as the technique of the operation was perfected and greater experience 
was acquired in its performance. The improved Cesarean section and 
Porro's operation have, however, of late years shown such good results 
that laparo-elytrotomy has fallen into disfavor. It does not appear to 
have been performed since 1887, and as it is a complex and difficult 
procedure it is not likely again to be adopted ; nor, with the lessened 
mortality of the Csesarean section, is there any reason why it should 
be. I do not, therefore, think it necessary to retain the lengthy ac- 
count of the anatomy of the parts concerned and of the technique of the 

'- Arch. f. Gvnak., Bd. xl. S. 117. 

2 It mav interest the reader to learn the views of my American editor, Dr. Harris, of Philadel- 
phia, on this subject. It is well known that Dr. Harris has devoted an immense amount of time 
and labor to the studv of these operations, on which he may be taken to be one of our most reli- 
able authorities. He" says: "We believe that the Porro operation will, in all probability, meet 
with better success than 'the conservative,' in Great Britain, from the fact that the last five cases 
in order have recovered. Holding the views there generally advocated, the section will only be 
made in badlv deformed rhachitic dwarfs and in the subjects of malacosteon, which are much 
more frequentlv thus delivered than the former. These will probably do better under the exsec- 
tive method, which besides has the advantage that it sometimes cures malacosteon, as shown by 
the results in Continental Europe."— Harris, note to seventh American edition. 



540 OBSTETRIC OPERATIONS. 

operation contained in former editions. It will suffice to give a brief 
account of its history and nature as a matter of obstetric interest. 

History. — The earliest suggestion of a procedure of this character 
seems to have been made by Joerg in the year 1806, who proposed a 
modified Cesarean section without incision of the uterus, by the divi- 
sion of the linea alba and of the upper part of the vagina, the foetus 
being extracted through the cervix. This suggestion was never carried 
into practice, and it is obvious that it misses the one chief advantage 
of laparo-elytrotomy, the leaving of the peritoneum intact. In 1820 
Ritgen proposed and actually attempted an operation much resembling 
Thomas's, in which section of the peritoneum was avoided. He failed, 
however, to complete it, and was eventually compelled to deliver his 
patient by the Caesarean section. In 1823, Baudelocque the younger 
independently conceived the same idea, and actually carried it into 
practice, although without success. Lastly, in 1837, Sir Charles Bell 
suggested a similar operation, clearly perceiving its advantages. Hence 
it appears that previous to Thomas's recent work in the matter, the 
operation was independently invented no less than three times. It 
fell, however, entirely into oblivion, and was only occasionally men- 
tioned in systematic works as a matter of curious obstetric history, no 
one apparently appreciating the promising character of the procedure. 

In the year 1870, Dr. T. Gaillard Thomas, of New York, read a 
paper before the Medical Association of Yonkers, entitled " Gastro- 
elytrotomy, a Substitute for the Csesarean Section," in which he de- 
scribed the operation as he had performed it three times on the dead 
subject, and once on a married woman in 1870, with a successful issue 
as regards the child. It seems beyond doubt that Thomas invented 
the operation for himself, being ignorant of Ritgen's and Baudelocque's 
previous attempts, and it is certain, to quote Garrigues, 1 that to him 
"belongs the glory of having been the first who performed gastro- 
elytrotomy so as to extract a living child from a living mother in his 
first operation, and of having brought both mother and child to com- 
plete recovery in his second operation." 

Since Thomas's first case, the operation has been performed several 
times in America, and has found its way across the Atlantic, having 
been twice performed in England, by Himes in Sheffield, by Edis in 
London j and by Poullet in Lyons, France. 

Nature of the Operation. — The object of laparo-elytrotomy is to 
reach the cervix by incision through the lower part of the abdominal 
wall and upper part of the vagina, and through it to extract the foetus 
as may most easily be done. 

Advantages over the Csesarean Section. — The advantages it is 
supposed to offer over the Caesarean section are that in dividing the 
abdomen the abdominal wall only is incised, and the peritoneum is left 
intact. The vagina is divided, but incision of the uterine parietes, 
which forms one of the chief risks of the Caesarean section, is entirely 
avoided. As against this, however, there is considerable risk from 
hemorrhage from the vessels of the cut or torn vagina. 

1 New York Med. Journ., vol. xxviii. pp. 337, 449. 



LAPARO-ELYTROTOMY AND SYMPHYSEOTOMY. 541 

Nature of the Operation. — It will suffice to say that the main 
step of the operation is an incision parallel to and about the same length 
as Poupart's ligament. Through this access is gained to the roof of 
the vagina, the peritoneum being lifted up and retracted, but not 
opened. The vagina is then pushed up by a blunt instrument and 
torn or cut open, the fundus uteri is depressed by an assistant to the 
opposite side, and the foetus extracted through the cervix without in- 
cising the uterine muscle. As the operation is practically obsolete no 
more need be said about it 

Symphyseotomy. — The second operation requires a more extended 
notice, since it has been revived within the last few years, chiefly under 
the auspices of Professor Morisani, of Naples, and has now been per- 
formed in a large number of cases, as an alternative to craniotomy, and 
with very considerable success. 

Its History. — In 1768 Sigault, then a medical student in Paris, 
suggested symphyseotomy , which consists in a division of the symphysis 
pubis, with a view of allowing the pubic bones to separate sufficiently 
to admit of the passage of the child. Although at first strongly op- 
posed, it was subsequently ardently advocated by many obstetricians, 
and frequently resorted to on the Continent. In 1778 the operation 
was performed eleven times in Germany, France, and Belgium ; once 
only in England, in 1782. Since that time it gradually fell into dis- 
favor, and may be said to have become practically obsolete, a few cases 
only having occasionally been operated on in Italy, where suitable 
cases of pelvic deformity appear to be very common. In 1863 Professor 
Morisani, of Naples, uudertook a study of the operation on the dead 
subject, and came to the conclusion that it had a sound basis, and in 
1866 he operated on a living woman, saving both the mother and 
child. Since that time it has been performed many times both on the 
Continent and in America, and in a few cases in this country, but it 
has never been popularized with us. There have been long runs of 
successful cases, but still the operation is by no means free of consider- 
able risk. Harris, 1 of Chicago, estimates the mortality between 1887 
and 1893 as being from 10.7 to 12.3 per cent., that is, one death in 
every ten patients operated on ; which is, however, probably a higher 
mortality than will be met with in the hands of experienced operators 
who have frequent opportunities of performing the operation. Thus 
Zweifel, 2 of Leipsic, had 31 consecutive successful between 1894 and 
1897, 29 of the children being born alive. 

These figures are certainly very striking, and the remarkably dimin- 
ished mortality is beyond doubt due to the application of careful anti- 
sepsis and improved technique. The maternal mortality will certainly 
contrast favorably with that attending an equal number of severe 
craniotomies, in all of which the children would have been sacrificed. 
It is to be noted, however, that this operation can never take the place 
of the Csesarean section in extreme cases of pelvic deformity, but is 
rather a substitute for craniotomy in slighter cases, chiefly in flattened 
pelves, which are just too small to admit of the passage of a living child. 

' "Symphyseotomy," bv M. L. Harris, M.D., Amer. Journ. of Obstet., December, 1804. 
* Annal. deGyn., Oct., 1897. 



542 OBSTETRIC OPERATION'S. 

It is not applicable in cases of obliquely contracted pelves, or in cases 
in which delivery is obstructed by tumors of any kind, bony growths, 
or carcinoma. It has also been suggested in certain cases in which 
the head is impacted in consequence of malpresentation, such as 
meuto-posterior positions of the face, or in brow-presentations, in 
which craniotomy would otherwise be necessary. 1 Any alternative 
that will avoid the destruction of a living foetus is surely well worthy 
of consideration, and there can be little doubt that the revival of sym- 
physeotomy will lead to its adoption in suitable cases. The operation 
is not in itself a difficult one. It may readily enough be undertaken 
by any one familiar with its technique, and accustomed to strict anti- 
septic surgery, but it is obviously of a nature much better suited for 
hospitals than for private practice, since it requires several assistants, 
and involves somewhat elaborate arrangements. 

Limits of the Operation. — Professor Morisani lays down two and 
three-quarter inches as the limit below which symphyseotomy is im- 
practicable. It would, of course, be a matter of great moment to 
ascertain the exact dimensions of the sacro-pubic diameter accurately, 
whenever the operation is contemplated, but as the necessity for this 
may not arise until the patient is actually in labor, this may not always 
be practicable. It is, however, in cases with a conjugate larger than 
this, iu which we would otherwise be obliged to resort to perforation, 
that this alternative will most frequently present itself in the hope of 
saving the life of the child. It is in such cases as the following, 
quoted by Harris, in which the contraction is not excessive, that sym- 
physeotomy will probably find its best application : " The patient was 
in labor for the third time. Her first child having been a large one, 
perished; the second being much smaller, lived ; and the third was 
again too large to pass. She had a diagonal conjugate of 100 milli- 
metres (four inches), and probably three and three-quarters inches in 
the true conjugate. The foetus, which was arrested at the superior 
strait, was delivered in fifteen minutes, by the vertex under manual 
assistance, after her pubes had been opened by the knife. The child 
was saved instead of perishing under the perforator; the mother made 
a good recovery, and was well in thirty days." 

Having no personal experience of this operation, I do not feel jus- 
tified in giving an opinion on its merits, beyond the obvious remark 
that anything that tends to minimize the resort to the horrible opera- 
tion of craniotomy, without materially increasing the risk to the mother, 
which the figures show that this operation, when properly performed, 
certainly does, is well worthy of the most serious study and considera- 
tion. 

The accompanying diagrams (Figs. 189, 190) will give an idea of 
the increased pelvic dimensions obtained by symphyseotomy. It rep- 
resents sections at the pelvic brim made on a subject who had died 
nine days after delivery at term. After division of the symphysis a 
separation of three inches took place, which is the average amount to 
be expected, and this gives about an inch gain on all the pelvic diame- 

1 " Symphyseotomy— a Successful Case," by J. Edwin Michael, M.A., M.D. Amer. Journ. of 
Obstet., February 1, 1893, p. 183. 



LAPARO-ELYTROTOMY AND SYMPHYSEOTOMY. 



543 



ters. This increase is well illustrated by the second figure, which 
shows the same section with the pubic bones placed in contact. This 
is closely approximate to the actual increase in the diameters found to 




Fig. 190. 




"AT SIZE 
Sections of pelvic brim to illustrate symphyseotomy. (After Pinard.) 

occur in practice, which is estimated by Pinard and others as from 
three-quarters of an inch to an inch. 

The only actual risk in the operation at the time of its performance 



544 OBSTETRIC OPERATIONS. 

is hemorrhage, which occasionally is very sudden, severe, and difficult 
to control. It arises from laceration of the venous plexus about the 
neck of the bladder, or of the erectile tissue of the urethra and clitoris, 
produced by the stretching of the fibrous tissue surrounding them. In 
one case recorded by Treub 1 this proved fatal. The best way of pre- 
venting and dealing with this complication will be mentioned in de- 
scribing the operation. The urethra has been torn in a few cases. 
Tne other risks are from septic complications, which should always be 
avoided by due care. 

No special instruments are required beyond scalpels, scissors, pressure 
forceps, silver wire, and aseptic ligatures, either gut or silk, needles, iodo- 
form gauze, strapping, and bandages. A sickle-shaped knife (Fig. 191) 

Fig. 191. 




Galbiati's sickle-shaped bistoury. 

has been invented by Galbiati for dividing the symphysis, but a strong, 
straight, blunt-pointed bistoury answers equally well, or even better. 

Before commencing it is essential that the cervix should be fully 
dilated. If dilatation has not been completed serious results might 
follow in consequence of delay subsequent to the section of the pubes. 
If, therefore, the os is not fully open, a Champetier de Ribes bag should 
be introduced and inflated before the operation is commenced. 

The patient should be placed on an operating-table of convenient 
height, the operator being seated between her thighs. Two or three 
assistants will be essential to support the patient in the lithotomy posi- 
tion, to move the thighs as may be necessary during the operation, and 
to apply pressure to the ilia as required. 

The vulva should be shaved, and then thoroughly purified, as also 
the vagina, first by soap and water, and then with 1 in 1000 solution 
of perchloride of mercury. 

The incision is commenced immediately above the pubes, and carried 
down in the mesial line until it reaches the clitoris, bleeding points 
being secured by pressure forceps. Any injury to this is best avoided 
by snipping through the suspensory ligament, when it can be drawn 
out of the way. The tissues are cut down to the bone, and the inser- 
tion of the recti muscles divided on either side. A bladder sound is 
introduced and intrusted to an assistant to draw the bladder and 
urethra out of the way. The index-finger is now passed through the 
divided recti, and the peritoneum and neighboring tissues thoroughly 
separated from the posterior surface of the pubes. The next step is 
the division of the symphysis. Most operators prefer to do this from 
before backward, the anterior being wider than the posterior surfaces, the 

i Annal. de Gyn., 1893. 



LAPARO-ELYTROTOMY AND SYMPHYSEOTOMY. 545 

structures behind being carefully guarded by the index-finger of the 
left hand. If Galbiati's knife is used, it is divided from below up- 
ward. Avers 1 strongly recommends subcutaneous section of the 
symphysis from behind forward ; but, although he has had excellent 
results, they do not appear to be better than those obtained by Pinard, 
Zweifel, and others who have large experience of the operation. 
While the symphysis is being cut the thighs and sides of the pelvis 
should be carefully supported. In some cases, when this precaution 
has been neglected, the bones have suddenly separated, the fibrous tissue 
has been stretched and torn, and alarming hemorrhage has resulted. 
Harris attaches special importance to the division of the sub-pubic 
ligament and the fibrous fascia attached to the posterior surface of the 
bones. These are divided by a blunt-pointed bistoury, guided by the 
finger, closely following the bones. When this is done, not only do 
the bones separate more widely, but the fibrous tissues are relaxed, and 
laceration of vessels prevented. 

It is at this stage of the operation that serious hemorrhage is likely 
to occur. 

The best way of controlling it is to press the thighs together, so as 
to relax the torn fibrous tissue attached to the bleeding vessels, and 
then to thoroughly plug the cavity behind the symphysis, counter pres- 
sure being kept up, if needful, by two fingers of the left hand inserted 
into the vagina. It is obviously impossible to seize and tie the bleed- 
ing points, which are out of sight and reach. 

The wound may now be temporarily covered with a pledget of gauze 
soaked in perchloride solution and left until delivery is completed. If 
the pains are strong and effective this may be left to nature; probably, 
however, it will be safer and better to expedite delivery by the forceps. 
During extraction an assistant should support the ilia, and evert the 
thighs, if needful, to increase the separation of the divided symphysis. 

Finally, the wound is closed by three or four deep sutures involving 
the fibrous tissues covering the symphysis, and superficial continuous 
sutures of the incision. The bones have been drilled and brought 
together by silver wire. The most experienced operators, however, do 
not consider this necessary, and have been quite satisfied with ordinary 
methods of treating the wound. The pelvis should then be supported 
either by wide strips of adhesive plaster, or by a firm bandage round 
the bones, and the wound dressed with antiseptic dressings. 

One would naturally fear that after the section of the symphysis, and 
the strain put on the sacro-iliac joints by the separation of the innomi- 
nate bones, subsequent difficulties in locomotion would arise. No men- 
tion is made of this in cases hitherto published, and Varnier, 2 whose 
experience is large, says that the operation gives rise to no trouble in 
future labors, and may easily be repeated. 

1 American Journal of Obstetrics, July, 1897. 

2 Annal. >\e Gyn., October, 1>/J7. 



35 



546 OBSTETRIC OPERATIONS. 



CHAPTEE VIII. 

THE TEANSFUSION OF BLOOD. 

The Transfusion of Blood in desperate and apparently hopeless 
cases of hemorrhage offers a possible means of rescuing the patient 
which merits careful consideration. It has again and again attracted 
the attention of the profession, but has never become popularized in 
obstetric practice. The reason of this is not so much the inherent 
defects of the operation itself — for quite a sufficient number -of success- 
ful cases are recorded to make it certain that it is occasionally a most 
valuable remedy — but the fact that the operation has been considered 
a delicate and difficult one, and that it has been deemed necessary to 
employ a complicated and expensive apparatus, which is never at hand 
when a sudden emergency arises. Whatever may be the difference of 
opinion about the value of transfusion, I think it must be admitted 
that it is of the utmost consequence to simplify the process in every 
possible way ; and it is above all things necessary to show that the 
steps of the operation are such as can be readily performed by any 
ordinarily qualified practitioner, and that the apparatus is so simple 
and portable as to make it easy for any obstetrician to have it at hand. 
There are comparatively few who would consider it worth w r hile to 
carry about with them, in ordinary every-day work, cumbrous and 
expensive instruments which may never be required in a life-long 
practice ; and hence it is not unlikely that, in many cases in which 
transfusion might have proved useful, the opportunity of using it has 
been allowed to slip. Of late years the operation has attracted much 
attention, the method of performing it has been greatly simplified, 
and I think it will be easy to prove that all the essential apparatus 
may be purchased for a few shillings, and in so portable a form as to 
take up little or no room ; so that it may be always carried in the 
obstetric bag ready for any possible emergency. 

History of the Operation. — The history of the operation is of con- 
siderable interest. In Yillari's Life of Savonarola, it is said to have 
been employed in the case of Pope Innocent VIII., in the year 1492, 
but I am not aware on what authority the statement is made. The 
first serious proposals for its performance do not seem to have been 
made until the latter half of the seventeenth century. It w T as first 
actually performed in France by Denis, of Montpellier, although 
Lower, of Oxford, had previously made experiments on animals which 
satisfied him that it might be undertaken with success. In November, 
1667, some months after Denis's case, he made a public experiment at 
Arundel House, in which twelve ounces of sheep's blood were injected 
into the veins of a healthy man, who is stated to have been very well 



THE TRANSFUSION OF BLOOD. 547 

after the operation, which must, therefore, have proved successful. 
These nearly simultaneous cases gave rise to a controversy as to priority 
of invention, which was long carried on with much bitterness. 

The idea of resorting to transfusion after severe hemorrhage does 
not seem to have been then entertained. It was recommended as a 
means of treatment in various diseased states, or with the extravagant 
hope of imparting new life and vigor to the old and decrepit. The 
blood of the lower animals only was used ; and, under these circum- 
stances, it is not surprising that the operation, although practised on 
several occasions, was never established as it might have been had its 
indications been better understood. 

From that time it fell almost entirely into oblivion, although experi- 
ments and suggestions as to its applicability were occasionally made, 
especially by Dr. Harwood, Professor of Anatomy at Cambridge, who 
published a thesis on the subject in the year 1785. He, however, 
never carried his suggestions into practice, and, like his predecessors, 
only proposed to employ blood taken from the lower animals. In the 
year L824 Dr. Blundell published his well-known work entitled 
Researches, Physiological and Pathological, which detailed a large 
number of experiments ; and to that distinguished physician belongs 
the undoubted merit of having brought the subject prominently before 
the profession, and of pointing out the cases in which the operation 
might be performed with hopes of success. Since the publication of 
this work, transfusion has been regarded as a legitimate operation 
under special circumstances ; but, although it has frequently been per- 
formed with success, and in spite of many interesting monographs on 
the subject, it has never become so established as a general resource 
in suitable cases as its advantages would seem to warrant. Within 
the last few years more attention has been paid to the subject, and the 
writings of Panum, Martin, and De Belina on the Continent, and of 
Higginson, McDonnell, Hicks, Aveling, and Schafer in Great Britain, 
amongst others, have thrown much light on many points connected 
with the operation. 

Nature and Object of the Operation. — Transfusion is practically 
only employed in cases of profuse hemorrhage connected with labor, 
although it has been suggested as possibly of value in certain other 
puerperal conditions, such as eclampsia or puerperal fever. Theo- 
retically it may be expected to be useful in such diseases ; but, inas- 
much as little or nothing is known of its practical effects in these 
diseased states, it is only possible here to discuss its use in cases of 
excessive hemorrhage. Its action is probably twofold: first, the 
actual restitution of blood which has been lost; second, the supply of 
a sufficient quantity of blood to stimulate the heart to contraction, and 
thus to enable the circulation to be carried on until fresh blood is 
formed. The influence of transfusion as a means of restoring lost 
blood must be trivial, since the quantity required to produce an effect 
is generally very small iudeed, and never sufficient to counterbalance 
that which has been lost. Its stimulant action is no doubt of far more 
importance; and if the operation be performed before the vital energies 
are entirely exhausted, the effect is often most marked. 



548 OBSTETRIC OPERATIONS. 

Use of Blood taken from the Lower Animals. — In the earliest 
operations the blood used was always that of the lower animals, gener- 
ally of the sheep. It has been thought by Brown-Sequard and others 
that the blood of some of the lower animals, especially of those in which 
the corpuscles are of smaller size than in man, as of the sheep, might 
be used with safety, provided it is not too rich in carbonic acid and 
too poor in oxygen, and injected in small quantity only. Landois, 1 
however, has conclusively proved that the blood of any of the lower 
animals has a most injurious effect on the human red corpuscles, which 
rapidly become swollen and decolorized, and discharge their coloring 
matter into the serum. It is certain, therefore, that this plan cannot 
be adopted in practice. 

The great practical difficulty in transfusion has always been the 
coagulation of the blood very shortly after it has been removed from 
the body. When fresh-drawn blood is exposed to the atmosphere, the 
fibrin commences to solidify rapidly, generally in from three to four 
minutes, sometimes much sooner. It is obvious that the moment 
fibrination has commenced, the blood is, ipso facto, unfitted for trans- 
fusion, not only because it can be no longer passed readily through the 
injecting apparatus, but because of the great danger of propelling small 
masses of fibrin into the circulation, and thus causing embolism. 
Hence, if no attempt be made to prevent this difficulty, it is essential, 
no matter what apparatus is used, to hurry on the operation so as to 
inject before fibrination has begun. This is a fatal objection, for there 
is no operation in the whole range of surgery in which calmness and 
deliberation are so essential, the more so as the surroundings of the 
patient in these unfortunate cases are such as to tax the presence 
of mind and coolness of the practitioner and his assistants to the 
utmost. 

All the recent improvements have had for their object the avoidance 
of coagulation, and practically this has been effected in one of three 
ways : First, by immediate transfusion from arm to arm, without 
allowing the blood to be exposed to the atmosphere, according to the 
methods proposed by Aveling, Eoussel, and Schafer. Second, by add- 
ing to the blood certain chemical reagents which have the property of 
preventing coagulation. Third, removal of the fibrin entirely by- 
promoting its coagulation and straining the blood, so that the liquor 
sanguinis and blood corpuscles alone are injected. 

Inasmuch as the success of the operation altogether depends on the 
method adopted, it will be well, before going further, to consider briefly 
the advantages and disadvantages of each of these plans. 

Aveling's Method. — The method of immediate transfusion has 
been brought prominently before the profession by Dr. Aveling, who 
has invented an ingenious apparatus for performing it. The apparatus 
consists essentially of a miniature Higginson's syringe, without valves, 
and with a small silver canula at either end. One canula is inserted 
into the vein of the person supplying blood, the other into a vein of 
the patient, and by a curious manipulation of the syringe, subsequently 

1 Die Transfusion des Blutes, Leipzig, 1875. 



THE TRANSFUSION OF BLOOD. 549 

to be described, the blood is carried from one vein into the other. It 
must be admitted that if there were no practical difficulties, this instru- 
ment would be admirable, and it is, therefore, not surprising that it 
should have met with so much favor from the profession. I cannot 
but think, however, that the operation is not so simple as at first sight 
appears, and that therefore it wants one of the essential elements 
required in any procedure for performing transfusion. One of my 
objections is, that it is by no means easy to work the apparatus without 
considerable practice. Of this I have satisfied myself by asking mem- 
bers of my class to work it after reading the printed directions, and 
finding that they are not always able to do so at once. Of course, it 
may be said that it is easy to acquire the necessary manipulative skill ; 
but when the necessity for transfusion arises, there is not time left for 
practising with the instrument, and it is essential that an apparatus, 
to be universally applicable, should be capable of being used imme- 
diately and without previous experience. Other objections are — the 
necessity of several assistants, the uncertainty of there being a sufficient 
circulation of blood in the veins of the donor to afford a constant 
supply, and the possibility of the whole apparatus being disturbed by 
restlessness or jactitation on the part of the patient. For these reasons 
it seems to me that this plan of immediate transfusion is not so simple, 
nor so generally applicable, as defibrination. Still, it is impossible not 
to recognize its merits, and it is certainly well worthy of further study 
and investigation. 

Roussel's Method. — Another method of immediate transfusion is 
that recommended by Roussel, 1 whose apparatus has recently attracted 
considerable attention. It possesses many undoubted advantages, and 
is beyond doubt a valuable addition to our means of performing the 
operation. It has, however, the great disadvantage of being costly 
and complicated, and hence I do not believe that it is likely to come 
into general use. 

Schafer's Method. — The third method is that recommended by Dr. 
Schafer in his recent excellent reports on transfusion submitted to the 
Obstetrical Society. 2 Schafer suggests two methods of performing the 
operation : one from vein to vein, the other from artery to artery. 
The latter, he holds, has the advantage of supplying pure oxygenated 
blood, under the best possible conditions for securing the amelioration 
of a patient suffering from the effects of profuse hemorrhage. The 
necessary operative proceedings are, however, somewhat complicated, 
and it seems to me very doubtful if this plan is likely to be at all 
commonly used. His method of immediate transfusion, however, is 
very simple, and is well worthy of trial. In his experiments on the 
lower animals it answered admirably. I am not aware that it has yet 
been tried on the human subject, but I do not sec any practical diffi- 
culty in its application. For the description of the operation I have 
inserted Dr. Schafer's own directions for the performance of venous 
immediate transfusion. 

The second plan for obviating the bad effects of clotting is the addi- 

1 Obstetrical Transactions, vol. xviii. p. 2*0. 

2 Ibid., vol. xxi. p. 316. 



550 OBSTETRIC OPERATION'S. 

tion of some substance to the blood which shall prevent coagulation. 
It is well known that several salts have this property, and the experi- 
ments made in the case of cholera patients prove that solutions of some 
of them may be injected into the venous system without injury. This 
method has been specially advocated by Dr. Braxton Hicks, who uses 
a solution of three ounces of fresh phosphate of soda in a pint of water, 
about six ounces of which are added to the quantity of blood to be 
injected. He has narrated four cases l in which this plan was adopted 
successfully, so far as the prevention of coagulation was concerned. It 
certainly enables the operation to be performed with deliberation and 
care, but it is somewhat complicated, and it may often happen that 
the necessary chemicals are not at hand. A further objection is the 
bulk of fluid which must be injected, and there is reason to believe 
that this has in some cases seriously embarrassed the heart's action 
and interfered with the success of the operation. In many of the 
successful cases of transfusion the amount of blood injected has been 
very small, not more than two ounces. Dr. Richardson proposes to 
prevent coagulation by the addition of liquor amnion ise to the blood, 
in the proportion of two minims diluted with twenty minims of water 
to each ounce of blood. 

Defibrination of the Blood. — The last method, and the one which, 
on the whole, I believe to be the simplest and most effectual, is defibrina- 
tion. It has been chiefly practised in the British Isles by Dr. McDon- 
nell, of Dublin, who has published several very interesting cases in 
which he employed it, and on the Continent by Martin, of Berlin, and 
De Belina, of Paris. The process of removing the fibrin is simple in 
the extreme, and occupies a few minutes only. Another advantage is 
that the blood to be transfused may be prepared quietly in an adjoining 
apartment, so that the operation may be performed with the greatest 
calmness and deliberation, and the donor is spared the excitement and 
distress which the sight of the apparently moribund patient is apt to 
cause, and which, as Dr. Hicks has truly pointed out, may interfere with 
the free flow of blood. The researches of Panum, Brown-Sequard, and 
others have proved that the blood corpuscles are the true vivifying 
element, and that defibrinated blood acts as well in every respect as that 
containing fibrin. It has been proved that the fibrin is reproduced within 
a short time, 2 and the whole tendency of modern research is to regard 
it, not as an essential element of the blood, but as an excrementitious 
product, resulting from the degradation of tissue, which may, therefore, be 
advantageously removed. Another advantage derived from defibrina- 
tion is, that the corpuscles are freely exposed to the atmosphere, oxygen 
is taken up, and carbonic acid given off, and the dangers which Brown- 
Sequard has shown to arise from the use of blood containing too much 
carbonic acid are thereby avoided. There can be, therefore, no physi- 
ological objection to the removal of the fibrin, which, moreover, takes 
away all practical difficulty from the operation. The straining to 
which the defibrinated blood is subjected entirely prevents the possi- 
bility of even the most minute particle of fibrin being contained in the 

i Guy's Hospital Reports, vol. xiv. 3d series, p. 1. 
2 Panum : Virchow's Arch., vol. xxvii. 



THE TRANSFUSION OF BLOOD. 551 

injected fluid ; the risk from embolism is, therefore, less than in any 
of the other processes already referred to. My own experience of this 
plan is limited to three cases, but in two it answered so well that I can 
conceive no reasonable objection to it. I should be inclined to say that 
transfusion, thus performed, is amongst the simplest of surgical oper- 
ations — an opinion which the experience of McDonnell and others 
fully confirms. 

Transfusion of Milk. — Recently the intra-venous injection of 
freshly-drawn warm milk has been recommended as a substitute for 
blood, chiefly in America. It was first used by Dr. Hodder, of 
Toronto, but has been introduced and strongly advocated by Thomas, 
of New York, who has used it twice after ovariotomy. Brown-Sequard, 
in experimenting on the lower animals, found that it answered as well 
as either fresh or defibrinated blood, and about half an hour after the 
injection no trace of the milk corpuscles could be found in the blood. 
Sehiifer, however, found that the action of milk on the blood corpuscles 
was highly deleterious, and that it introduces the germs of septic 
organisms likely to produce very serious results. He, therefore, pro- 
nounces strongly against its use. 

Injection of Saline Solutions. — Dr. William Hunter 1 has recently 
published a series of valuable observations on the subject of transfusion. 
His conclusions are that its principal effects are those of stimulation, 
and that, for all practical purposes, in cases of severe hemorrhage, the 
injection of a saline solution is quite as efficacious, and much simpler. 
For this purpose all that is required is a glass canula, such as Schiller's, 
a piece of India-rubber tubing, and a syringe, all of which should be, 
of course, carefully asepticized. The fluid to be injected is very readily 
manufactured by dissolving a teaspoonful of common salt in a pint of 
water at a temperature of 100°. Horrocks 2 also strongly advises the 
injection of this saline infusion in preference to blood. He uses a 
canula and tube, with a glass funnel, the fluid entering the vein by 
gravitation. He says that when this is held at a height of three feet 
above the arm of the patient about a pint will enter into the vein in 
four minutes. Four out of seven cases in whch he adopted this plan 
recovered. It has been suggested 3 that the injection of the same solu- 
tion into the muscular tissues will auswer equally well. For this pur- 
pose the needle of an aspirator is attached by a piece of India-rubber 
tubing to an ordinary glass funnel. The needle is inserted into the 
gluteal region or loins, and the saline infusion poured into the funnel. 
After it has entered the tissues it is diffused by massage. Both these 
methods have the great advantage of simplicity, and, if further expe- 
rience proves them to be as efficacious as they are said to be, will prove 
valuable in many cases in which the transfusion of blood cannot be 
employed. 

Statistical Results. — The number of cases of transfusion are per- 
haps not sufficient to admit of completely reliable conclusions. It is 
certain, however, that transfusion has often been the means of rescuing 

i Brit. Med. Journ., vol. ii.. I 

- M'inchmever . Arch, fur Gynak., Bel. xxxiv. Hft. 3. 

s Obst. Trans., lS'Jl. 



552 OBSTETRIC OPERATIONS. 

the patient when apparently at the point of death, and after all other 
means of treatment had failed. Professor Martin records 57 cases, in 
43 of which transfusion was completely successful, and in 7 tem- 
porarily so ; while in the remaining 7 no reaction took place. Dr. 
Higginson, of Liverpool, has had 15 cases, 10 of which were suc- 
cessful. Figures such as these are encouraging, and they are sufficient 
to prove that the operation is one which at least offers a fair hope of 
success, and which no obstetrician would be justified in neglecting, 
when the patient is sinking from the exhaustion of profuse hemor- 
rhage. It is to be hoped also that further experience may prove it to 
be of value in other cases in which its use has been suggested, but not, 
as yet, put to the test of experiment. 

Possible Dangers of the Operation. — The possible risks of the 
operation would seem to be the danger of injecting minute particles of 
fibrin which form emboli ; of injecting bubbles of air ; or of overwhelm- 
ing the action of the heart by injecting too rapidly, or in too great 
quantity. These may be, to a great extent, prevented by careful atten- 
tion to the proper performance of the operation, and it does not clearly 
appear, from the recorded cases, that they have ever proved fatal. We 
must also bear in mind that transfusion is seldom or never likely to 
be attempted until the patient is in a state which would otherwise 
almost certainly preclude the hope of recovery, and in which, therefore, 
much more hazardous proceedings would be fully justified. 

Cases Suitable for Transfusion. — The cases suitable for trans- 
fusion are those in which the patient is reduced to an extreme state of 
exhaustion from hemorrhage during or after labor or miscarriage, 
whether by the repeated losses of placenta prsevia, or the more sudden 
and profuse flooding of post-partum hemorrhage. The operation will 
not be contemplated until other and simpler means have been tried and 
failed, or until the symptoms indicate that life is on the verge of ex- 
tinction. If the patient should be deadly pale and cold, with no pulse 
at the wrist, or one that is scarcely perceptible ; if she be unable to 
swallow, or vomits incessantly ; if she lie in an unconscious state ; if 
jactitation, or convulsions, or repeated faintings should occur ; if the 
respiration be laborious, or very rapid and sighing ; if the pupils do 
not act under the influence of light, it is evident that she is in a condi- 
tion of extreme danger, and it is under such circumstances that trans- 
fusion, performed sufficiently soon, offers a fair prospect of success. It 
does not necessarily follow because one or other of these symptoms is 
present that there is no chance of recovery under ordinary treatment, 
and, indeed, it is within the experience of all that patients have rallied 
under apparently the most hopeless conditions. But when several of 
them occur together, the prospect of recovery is much diminished, and 
transfusion would then be fully justified, especially as there is no reason 
to think that a fatal result has ever been directly traced to its employ- 
ment. Indeed, like most other obstetric operations, it is more likely 
to be postponed until too late to be of good service, than to be employed 
too early ; and in some of the cases reported as unsuccessful it was 
not performed until respiration had ceased and death had actually 
taken place. It has sometimes been said that transfusion should never 



THE TRANSFUSION OF BLOOD. 553 

be employed if the uterus be not firmly contracted, so as to prevent the 
injected blood again escaping through the uterine sinuses. The cases 
in which this is likely to occur are few ; and if one were met with, the 
escape of blood could be prevented by the injection into the uterus of 
the perchloride of iron. 

Description of the Operation. — In describing the operation I 
shall limit myself to an account of Aveling's and Sckafer's method of 
immediate transfusion, and to that of injecting deiibrinated blood. I 
consider myself justified in omitting any account of the numerous in- 
struments which have been invented for the purpose of injecting pure 
blood, since I believe the practical difficulties are too great ever to 
render this form of operation serviceable. The great objection to 
most of them is their cost and complexity ; and as long as any special 
apparatus is considered essential, the full benefits to be derived from 
transfusion are not likely to be realized. The necessity for employing 
it arises suddenly ; it may be in a locality in which it is impossible to 
procure a special instrument ; and it would be well if it were under- 
stood that transfusion may be safely and effectually performed by the 
simplest means. In many of the successful cases an ordinary syringe 
was used; in one, in the absence of other instruments, a child's toy 
syringe was employed. I have myself performed it with a simple 
syringe purchased at the nearest chemist's shop, when a special trans- 
fusion apparatus failed to act satisfactorily. 

Fig. 192. 




Method of transfusion by Aveling's apparatus. 

In immediate transfusion (Fig. 192), the donor is seated close to 
the patient, and the veins in the arms of each having been opened, 
the silver canula at either end of the instrument is introduced into 
them (a b). The tube between the bulb and the donor is now pinched 
(d), so as to form a vacuum, and the bulb becomes filled with blood 
from the donor. The finger i- now removed so as to compress the 
distal tube (d') 5 and the bulb being compressed (c), its contents are 
injected into the patient's vein. The bulb is calculated to hold 
about two drachms, so that the amount injected can be estimated by 
the number of times it is emptied. The risk of injecting air is pre- 



554 OBSTETRIC OPERATIONS. 

veoted by filling the syringe with water which is injected before the 
blood. 

Schafer's Directions for Immediate Transfusion. 

Direct Venous Transfusion. — "Procure two glass canulas of appro- 
priate size and shape (see Fig. 193), and a piece of black India-rubber 
tubing, seven inches long, and not less than a quarter of an inch bore, 
fitted to the canulas. This apparatus could always be improvised. 

" Place the transfusion-tube in a basin of hot water containing a 
little carbonate of soda. Put a tape around the arm of the patient 
just below the place where the vein is to be opened, and another just 
above. Expose the vein by an incision through the skin, which should 
be made transversely if the position of the vein cannot be made out 
through the skin. Clear a small piece of the vein with forceps, and 
slip a pointed piece of card underneath it. By a snip with scissors 
make an oblique opening into the vein, and partly insert a small 
blunt instrument (such as a wool-needle) so that the aperture is not 
lost. Remove the upper tape. Next prepare the vein of the giver. 
To do this put tapes around the arm just below and above the place 
where the vein is to be opened. Expose the vein by a longitudinal 
incision through the skin. Clear a small piece of the 
FlG - 193 - vessel with forceps and pass a thread ligature under- 

neath. A slip of card may also be placed under this 
vein. Make a snip into the vein just above the liga- 
ture, and then, taking the transfusion-tube out of the 
soda solution, slip one of the canulas into the vein 
of the giver, and tie it in with a simple knot, which 
can be readily untied. Let the giver go to the bed- 
side and place his arm alongside that of the patient. 
Hold the end of the India-rubber tube with the 
second canula up a little, and release the lower tape 
on the arm of the blood-giver. As soon as blood 
flows out of the second canula pinch the India-rubber 
tube close to the canula, so as to stop the flow, and, 
removing the wool-needle, slip the end of the canula 
into the vein of the patient, hold it there, and allow the blood to pass 
freely along the tube. Three minutes will generally be long enough 
for the flow, which can be stopped by compressing the vein of the 
giver below the canula. Both canulas may now be withdrawn and 
the ligature removed from the vein of the giver, the cut veins being 
dealt with in the usual way. Of course, the other tape on the arm of 
the donor must be removed as soon as the transfusion is over. 

" Instead of using the transfusion-tube empty, it may be filled with 
soda solution, to the exclusion of air. It is necessary to have one or 
two spring clips on the tube to prevent the escape of the solution. 
This is a much better plan than the other, for the blood need not be 
allowed to flow into the tube until the second canula is inserted, and 
then, by opening the clips, it may drive the soda solution before it 
into the vein. The small quantity of carbonate of soda solution neces- 
sary to fill the simple tube will do the patient no harm." 




THE TRANSFUSION OF BLOOD. 555 

Injection of Defibrinated Blood. — For injecting defibrinated blood 
various contrivances have been used. McDonnell's instrument is 
a simple cylinder with a nozzle attached, from which the blood is 
propelled by gravitation. When the propulsive power is insufficient, 
increased pressure is applied by breathing forcibly into the open end 
of the receiver. De Belina's instrument is on the same principle, 
only atmospheric pressure is supplied by a contrivance similar to 
Richardson's spray-producer, attached to one end. The idea is simple, 
but there is some doubt of a gravitation instrument being sufficiently 
powerful, and it certainly failed in my hands. I have had the valves 
applied to Aveling's instrument, so that it works by compression of 
the bulb, like an ordinary Hi^g-mson's syringe. This, with a single 
silver canula at one end for introduction into the vein, forms a per- 
fect and inexpensive transfusion apparatus, taking up little space. If 
it be not at hand, any small syringe with a fine nozzle may be used. 

The first step of the operation is defibrination of the blood, which 
should, if possible, be prepared in an apartment adjoining the patient's. 
The blood should be taken from the arm of a strong and healthy 
man. The quality cannot be unimportant, and in some recorded 
cases the failure of the operation has been attributed to the fact of the 
donor having been a weakly female. The supply from a woman 
might also prove insufficient ; and, although it has been shown that 
blood from two or more persons may be used with safety, yet such a 
change necessarily causes delay, and should, if possible, be avoided. 
A vein having been opened, eight or ten ounces of blood are with- 
drawn and received into some perfectly clean vessel, such as a dessert 
finger-glass. As it flows it should be briskly agitated with a clean 
silver fork or a glass rod, and very shortly strings of fibrin begin to 
form. It is now strained through a piece of fine muslin, previously 
dipped in hot water, into a second vessel which is floating in water at 
a temperature of about 105°. By this straining, the fibrin and all 
air-bubbles resulting from the agitation are removed; and if there be 
no excessive hurry, it might be well to repeat the straining a second 
time. If the vessel be kept floating in warm water, the blood is pre- 
vented from getting cool, and we can now proceed to prepare the arm 
of the patient for injection. 

This is the most delicate and difficult part of the operation, since the 
veins are generally collapsed and empty, and by no means easy to 
find. The best way of exposing them is that practised by McDon- 
nell, who pinches up a fold of the skin at the bend of the elbow, and 
transfixes it with a line tenotomy knife or scalpel, so making a gaping, 
wound in the integument, at the bottom of which they are seen lying. 
A probe should now be passed underneath the veiu selected for opening, 
so as to avoid the chance of its being lost at any subsequent stage of 
the operation. This is a point of some importance, and from the 
neglect of this precaution I have been obliged to open another vein 
than that originally fixed on. A small portion of the vein being raised 
with the forceps, a nick is made into it for passage of the canula. 

Injection of the Blood. — The prepared blood is now brought to the 
bedside, and the apparatus having been previously filled with blood to 



556 OBSTETRIC OPERATIONS. 

avoid the risk of injecting any bubbles of air, the canula is inserted 
into the opening made in the vein, and transfusion commenced. It 
should be constantly borne in mind that this part of the operation 
should be conducted with the greatest caution, the blood introduced 
very slowly, and the effect on the patient carefully watched. The 
injection may be proceded with until some perceptible effect is pro- 
duced, which will generally be a return of the pulsation, first at the 
heart and subsequently at the wrist, an increase in the temperature of 
the body, greater depth and frequency of the respirations, and a general 
appearance of returning animation about the countenance. Sometimes 
the arms have been thrown about, or spasmodic twitchings of the face 
have taken place. The quantity of blood required to produce these 
effects varies greatly, but in the majority of cases has been very small. 
Occasionally two ounces have proved sufficient, and the average may 
be taken as ranging between four and six ; although in a few cases 
between ten and twenty have been used. The practical rule is to pro- 
ceed very slowly with the injection until some perceptible result is ob- 
served. Should embarrassed or frequent respiration supervene, we 
may suspect that we have been injecting either too great a quantity of 
blood, or with too much force and rapidity, and the operation should 
at once be suspended, and not resumed until the suspicious symptoms 
have passed away. It may happen that the effects of the transfusion 
have been highly satisfactory, but that in the course of time there is 
evidence of returning syncope. This may possibly be prevented by 
the administration of stimulants, but if these fail there is no reason 
why a fresh supply of blood should not again be injected, but this 
should be done before the effects of the first transfusion have entirely 
passed away. 

Secondary Effects of Transfusion. — The subsequent effects in 
successful cases of transfusion merit careful study. In some few cases 
death is said to have happened within a few weeks, with symptoms 
resembling pysemia. Too little is known on this point, however, to 
justify any positive conclusions with regard to it. 



PART Y. 

THE PUERPERAL STATE. 



CHAPTEE I. 

THE PUERPERAL STATE AND ITS MANAGEMENT. 

Importance of Studying- the Puerperal State. — The key to the 
management of women after labor, and to the proper understanding of 
the many important diseases which may then occur, is to be found in 
a study of the phenomena following delivery, and of the changes going 
on in the mother's system during the puerperal period. ]S^o doubt 
natural labor is a physiological and healthy function, and during 
recovery from its effects disease should not occur. It must not be for- 
gotten, however, that none of our patients are under physiologically 
healthy conditions. The surroundings of the lying-in woman, the 
eifects of civilization, of errors of diet, of defective cleanliness, of 
exposure to contagion, and of a hundred other conditions which it is 
impossible to appreciate, have most important influences on the results 
of childbirth. Hence it follows that labor, even under the most favor- 
able conditions, is attended with considerable risk. 

The Mortality of Childbirth. — It is not easy to say with accuracy 
what is the precise mortality accompanying childbirth in ordinary 
domestic practice, since the returns derived from the reports of the 
Registrar-General, or from private sources, are manifestly open to seri- 
ous error. The nearest approach to a reliable estimate is that made 
by the late Dr. Matthews Duncan, 1 who calculated, from figures derived 
from various sources, that no fewer than 1 out of every 120 women, 
delivered at or near the full time, died within four weeks of childbirth. 
This indicates a mortality far above that which has been generally 
believed to accompany childbearing under favorable circumstances. 
It, however, closely approximates to a similar estimate made by Mc~ 
Clintock, 2 who calculated the mortality in England and Wales as 1 in 
126 ; and in the upper and middle classes alone, where the conditions 
may naturally be supposed to be more favorable, at 1 in 146 ; more 
recently he had come to the conclusion from his own increased experi- 
ence, and the published results of the practice of others, that 1 in 100 
would more correctly represent the rate of puerperal mortality. 3 Id 

i The " Mortality of Childbed," Edin. Med. Journ., vol. 1869-70, p. 399. 
2 Dublin Quart. Journ. of Med. Science, vol. xlviii. p. 256. 
s Brit. Med. Journ., vol. ii. p. 215. 

(557) 



558 THE PUERPERAL STATE. 

these calculations there are some obvious sources of error, since they 
include deaths from all causes within four weeks of delivery, some of 
which must have been independent of the puerperal state. 

But it is not the deaths alone which should be considered. All 
practitioners know how large a number of their patients suffer from 
morbid states which may be directly traced to the effects of childbear- 
ing. It is impossible to arrive at any statistical conclusion on this 
point, but it must have a very sensible and important influence on the 
health of childbearing women. 

Alterations in the Blood after Delivery. — The state of the blood 
during pregnancy, already referred to (p. 146), has an important bear- 
ing on the puerperal state. There is hyperinosis, which is largely 
increased by the changes going on immediately after the birth of the 
child ; for then the large supply of blood which has been going to the 
uterus is suddenly stopped, and the system must also get rid of a 
quantity of effete matter thrown into the circulation, in consequence of 
the degenerative changes occurring in the muscular fibres of the uterus. 
Hence all the depurative channels by which this can be eliminated 
are called on to act with great energy. If, in addition, the peculiar 
condition of the generative tract be borne in mind — viz., the large open 
vessels on its inner surface, the partially bared inner surface of the 
uterus, and the channels for absorption existing in consequence of 
slight lacerations in the cervix or vagina — it is not a matter of surprise 
that septic diseases should be so common. 

It will be well to consider successively the various changes going 
on after delivery, and then we shall be in a better position for study- 
ing the rational management of the puerperal state. 

Some degree of nervous shock or exhaustion is observable after 
most labors. In many cases it is entirely absent ; in others it is well 
marked. Its amount is in proportion to the severity of the labor 
and the susceptibility of the patient ; and it is, therefore, most likely 
to be excessive in women who have suffered greatly from pain, who 
have undergone much muscular exertion, or who have been weakened 
from undue loss of blood. It is evidenced by a feeling of exhaustion 
and fatigue, and not uncommonly there is some shivering, which soon 
passes off, and is generally followed by refreshing sleep. The extreme 
nervous susceptibility continues for a considerable time after delivery, 
and indicates the necessity of keeping the lying-in patient as free from 
all sources of excitement as possible. 

Immediately after delivery the pulse falls, and the importance of 
this as indicating a favorable state of the patient has already been 
alluded to. The condition of the pulse has been carefully studied by 
Blot, 1 who has shown that this diminution, which he believes to be 
connected with a diminished tension in the arteries due to the sudden 
arrest of the uterine circulation, continues, in a large proportion of 
cases, for a considerable number of days after delivery ; and, as a 
matter of clinical import, as long as it does, the patient may be con- 
sidered to be in a favorable state. In many instances the slowness of 

1 Arch. gen. de Med., 1864. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 559 

the pulse is remarkable, often sinking to fifty or even forty beats per 
minute. Any increase above the normal rate, especially if at all con- 
tinuous, should always be carefully noted and looked on with suspi- 
cion. In counection with this subject, however, it must be remembered 
that in puerperal women the most trivial circumstances may cause 
a sudden rise of the pulse. This must be familar to every practical 
obstetrician, who has constant opportunities of observing this effect 
after any transient excitement or fatigue. In lying-in hospitals it has 
generally been observed that the occurrence of any particularly bad 
case will send up the pulse of all the other patients who may have 
heard of it. 

Temperature in the Puerperal State. — The temperature in the 
lying-in state affords much valuable information. During and for a 
short time after labor there is a slight elevation. It soon falls to, or 
even somewhat below, the normal level. Squire found that the fall 
occurred within twenty-four hours, sometimes within twelve hours 
after the termination of labor. 1 For a few days there is often a slight 
increase of temperature, especially toward the evening, which is prob- 
ably caused by the rapid oxidation of tissue in connection with the 
involution of the uterus. In about forty-eight hours there is a rise 
connected with the establishment of lactatiou, amounting to one or two 
degrees over the normal level ; but this again subsides as soon as the 
milk is freely secreted. Cred6 has also shown 2 that rapid, but transient, 
rises of temperature may occur at any period, connected with trivial 
causes, such as constipation, errors of diet, or mental disturbances. 
But if there be any rise of temperature which is at all continuous, 
especially to over 100° Fahr., aud associated with rapidity of the 
pulse, there is reason to fear the existence of some complication. 

The Secretions and Excretions. — The various secretions and ex- 
cretions are carried on with increased activity after labor. The skin 
especially acts freely, the patient often sweating profusely. There is 
also an abundant secretion of urine, but not uncommonly a difficulty 
of voiding it, either on account of temporary paralysis of the neck of 
the bladder, resulting from the pressure to which it has been subjected, 
or from swelling and occlusion of the urethra. For the same reason 
the rectum is sluggish for a time, aud constipation is not infrequent. 
The appetite is generally indifferent, aud the patient is often thirsty. 

Generally in about forty-eight hours the secretion of milk becomes 
established, and this is occasionally accompanied by a certain amount 
of constitutional irritation. The breasts often become turgid, hot, and 
painful. There may or may not be some general disturbance, quick- 
ening of pulse, elevation of temperature, possibly slight shivering and 
a general sense of oppression, which are quickly relieved as the milk 
is formed and the breasts emptied by suckling. Squire says that the 
most constant phenomenon connected with the temperature is a slight 
elevation as the milk is secreted, rapidly falling when lactation is 
established. Barker noted elevation, either of temperature <>r pulse, 
in only four out of fifty-two eases that were carefully watched. There 

1 " Puerperal Temperatures." Obstetrical Trasactions, vol. ix. p. 129. 

2 Monats. f. Geburt. Bd. xxxii. S. 453. 



560 THE PUERPERAL STATE. 

can be little doubt that the importance of the so-called " milk fever " 
has been immensely exaggerated, and its existence, as a normal accom- 
paniment of the puerperal state, is more than doubtful. It is certain, 
however, that in a small minority of cases there is an appreciable 
amount of disturbance about the time that the milk is formed. Out 
of 423 cases, Macau 1 found that in 114, or about 27 per cent., there 
was no rise of temperature ; in 226 the temperature did rise to 100° 
and over, and of these in 32, or a little over 7 cent., the only ascer- 
tainable cause was a painful or distended condition of the breast. 
Many modern writers, such as Winckel, Grimewaldt, and D'Espine, 
entirely deny the connection of this disturbance with lactation, and 
refer it to a slight and transient septicaemia. Graily Hewitt remarks 
that it is most commonly met with when the patient is kept low and 
on deficient diet after delivery, especially when the system is below 
par from hemorrhage or any other cause. This observation will, no 
doubt, account for the comparative rarity of febrile disturbance in 
connection with lactation in these days, in which the starving of puer- 
peral patients is not considered necessary. It is certain that anything 
deserving the name of milk fever is now altogether exceptional, and 
such feverishness as exists is generally quite transient. It is also a 
fact that it is most apt to occur in delicate and weakly women, espe- 
cially in those who do not, or are unable to, nurse. There does not, 
however, seem to be any sufficient reason for referring it, even when 
tolerably well marked, to septicaemia. The relief which attends the 
emptying of the breasts seems sufficient to prove its connection with 
lactation, and the discomfort which is necessarily associated with the 
swollen and turgid mamma? is, of itself, quite sufficient to explain it. 

In the urine of women during lactation an appreciable amount of 
sugar may readily be detected. The amount varies according to the 
condition of the breasts. It increases when they are turgid and con- 
gested, and is, therefore, most abundant in women in whom the 
breasts are not emptied, as when the child is dead, or when lactation is 
not attempted. 

Contraction of the Uterus after Delivery. — Immediately after 
delivery the uterus contracts firmly, and can be felt at the lower part 
of the abdomen as a hard, firm mass, about the size of a cricket-ball. 
(Plate VI. ) After a time it again relaxes somewhat, and alternate 
relaxations and contractions go on at intervals for a considerable time 
after the expulsion of the placenta. The more complete and perma- 
nent the contraction, the greater the safety and comfort of the patient ; 
for when the organ remains in a state of partial relaxation, coagula 
are apt to be retained in its cavity, while, for the same reason, air enters 
more readily into it. Hence decomposition is favored, and the chances 
of septic absorption are much increased ; while even when this does 
not occur, the muscular fibres are excited to contract, and severe after- 
pains are produced. 

After the first few days the diminution in the size of the uterus pro- 
gresses with great rapidity. By about the sixth day it is so much 

1 Dublin Quarterly Journ. of Med. Science, vol. lxv. p. 435. 



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THE PUERPERAL STATE AND ITS MANAGEMENT. 561 

lessened as to project not more than one and a half or two inches above 
the pelvic brim, while by the eleventh day it is no longer to be made 
out by abdominal palpation. Its increased size is, however, still ap- 
parent per vagi nam, and should occasion arise for making internal 
examination, the mass of the lower segment of the uterus, with its 
flabby and patulous cervix, can be felt for some weeks after delivery. 
This may sometimes be of practical value in cases in which it is neces- 
sary to ascertain the fact of recent delivery, and under these circum- 
stances, as pointed out by Simpson, the uterine sound would also enable 
us to prove that the cavity of the uterus is considerably elongated. 
Indeed, the normal condition of the uterus and cervix is not regained 
until six weeks or two months after labor. These observations are 
corroborated by investigations on the weight of the organ at different 
periods after labor. Thus Heschl 1 has shown that the uterus, imme- 
diately after delivery, weighs about twenty-two to twenty-four ounces ; 
within a week, it weighs nineteen to twenty-one ounces ; and at the 
end of the second week, ten to eleven ounces only. At the end of the 
third week, it weighs five to seven ounces ; but it is not until the end 
of the second month that it reaches its normal weight. Hence it 
appears that the most rapid diminution occurs during the second week 
after delivery. 

Patty Transformation of the Muscular Fibres. — The mode in 
which this diminution in size is effected has generally been stated to be 
by the transformation of the muscular fibres into molecular fat, which 
is absorbed into the maternal vascular system, which, therefore, 
becomes loaded with a large amount of effete material. Heschl 
believed that the entire mass of the enlarged uterine muscles is 
removed, and replaced by newly -formed fibres, which commence to be 
developed about the fourth week after delivery, the change being com- 
plete about the end of the second month. Luschka and Robin 2 con- 
tend that this entire change in the structure of the fibres does not 
occur, but that their diminution in size is effected by granular degen- 
eration and subsequent absorption of the existing muscle cells, by means 
of which they become gradually reduced to their natural size. This 
view has been more recently maintained by Sanger. The more recent 
researches of Helme 3 throw doubt on this theory. He investigated 
the uteri of rabbits after parturition, and found no fatty degeneration. 
He believes that there is a general shrinking of the muscular fibres, 
which undergo a chemical change, a sort of peptonization, which 
renders their absorption more easy. The old fibres do not appear to 
be destroyed, but they are diminished in size ; nor are any new ones 
formed. The connective tissue he describes as first becoming granular, 
and then gradually diminishing and disappearing. Generally speaking, 
involution goes on without interruption. It is, however, apt to be 
interfered with by a variety of causes, such as premature exertion, in- 
tercurrent disease, and very probably by neglect of lactation. Hence 
the uterus often remains large and bulky, and the foundation for 
many subsequent uterine ailments is laid. 

1 Researches on the Conduct of the Human Uterus after Deliveiv. 

2 "The Involution of the Muscular Tissue of the Puerperal Uterus," Annals of Gynecology, 
Boston, Julv, 188a 3 Trans. Royal Soc. of Edin., vol. xxxv. 

36 



562 



THE PUERPERAL STATE. 



Changes in the Uterine Vessels. — Williams 1 has drawn attention 
to changes occurring in the vessels of the uterus, some of which seem 
to be permanent, and may, should further observations corroborate his 
investigations, prove of value in enabling us to ascertain whether a 
uterus is nulliparous or the reverse ; a question which may be of 
medico-legal importance. After pregnancy he found all the vessels 
enlarged in calibre. The coats of the arteries are thickened and 
nypertrophied, and this he has observed even in the uteri of aged 
women who have not borne children for many years. The venous 
sinuses, especially at the placental site, have their walls greatly 
thickened and convoluted, and contain in their centre a small clot of 
blood (Fig. 194). This thickening attains its greatest dimensions in 
the third month after gestation, but traces of it may be detected as late 
as ten or twelve weeks after labor. 

Changes in the Uterine Mucous Membrane. — The changes going 
on in the lining membrane of the uterus immediately after delivery are 
of great importance in leading to a knowledge of the puerperal state, 
and have already been discussed when describing the decidua (p. 108). 

Fig. 194 




Section of a uterine sinus from the placental site nine weeks after delivery. 
(After Williams.) 

Its cavity is covered with a reddish-gray film, formed of blood and 
fibrin. The open mouths of the uterine sinuses are still visible, more 
especially over the site of the placenta, and thrombi may be seen pro- 
jecting from them. The placental site can be distinctly made out in 
the form of an irregularly oval patch, w r here the lining membrane is 



1 " Changes in the Uterus resulting from Gestation," Obst. Trans., vol. xx. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 563 

thicker than elsewhere. (See Plate VI.) The greater part of the 
endometrium is shed with the chorion and the amnion during labor, 
but the fundi of the tubular glands, lined with epithelium, and the 
surrounding connective tissue, remain. From these structures the 
endometrium commences to grow, and in six weeks or tw T o months 
after delivery a new mucosa is completely reformed. 

Contraction of the Vagina, etc. — The vagina soon contracts, and 
by the time the puerperal month is over it has returned to its normal 
dimensions, but after childbearing it always remains more lax and 
less rugose than in nullipara?. The vulva, at first very lax and much 
distended, soon regains its former state. The abdominal parietes re- 
main loose and flabby for a considerable time, and the white streaks, 
produced by the distention of the cutis very generally become per- 
manent. In some Avomen, especially when proper support by band- 
aging has not been given, the abdomen remains permanently loose and 
pendulous. 

The Lochial Discharge. — From the time of delivery up to about 
three Aveeks afterward a discharge escapes from the interior of the 
uterus, known as the lochia. At first this consists almost entirely of 
pure blood, mixed Avith a A^ariable amount of coagula. If efficient 
uterine contraction has not been secured after the expulsion of the 
placenta, coagula of considerable size are frequently expelled with the 
lochia for one or two days after delivery. In three or four days the 
distinctly bloody character of the lochia is altered. They have a red- 
dish watery appearance, and are knoAA*n as the lochia rubra or cruenta. 
According to the researches of Wertheimer, 1 they are at this time 
composed chiefly of blood corpuscles, mixed v%ith epithelium scales, 
mucous corpuscles, and the debris of the decidua. The change in the 
appearance of the discharge progresses gradually, and about the seA T enth 
or eighth day it has no longer a red color, but is a pale greenish fluid, 
Avith a peculiar sickening and disagreeable odor, and is familiarly 
described as the " green Avaters." It now contains a small quantity 
of blood corpuscles, which lessen in amount from day to day, and a 
considerable number of pus corpuscles, which remain the principal con- 
stituent of the discharge until it ceases. The pus, however, does not 
appear to be a normal constituent of the uterine lochia, but chiefly 
proceeds from the granulating surfaces of cervical and vaginal lacera- 
tions. 2 Besides these, epithelial scales, fatty granules, and crystals of 
cholesterin are observed. Various micro-organisms are found in the 
discharge, especially in the lower part of the vagina, such as the tricho- 
monas vaginalis, streptococci, gonococci, and others, and they increase 
in nnmbers toward the end of the week after delivery. The conditions 
existing in the vagina greatly favor their growth, and hence the special 
importance of strict attention to cleanliness and antiseptic precautious 
during convalescence. 

The amount of the lochia varies much, and in some women it is 
habitually more abundant than in others. Gassuer estimated the 

i Virchow's Arch., 1861. - Kronip. Centralbl. f. Gyniik., 1S95, No. 1G. 



564 THE PUERPERAL STATE. 

average amount to be about 54 ounces, while Giles, 1 who has carefully- 
studied the subject, fixes it at 10 ounces. This difference is probably 
due to the careful antiseptic used in his cases, which lessens both the 
amount and the duration of the discharge. Under ordinary circum- 
stances it is very scanty after the first fortnight, but occasionally it con- 
tinues somewhat abundant for a month or more, without any bad results. 

It is apt again to become of a red color, and to increase in quan- 
tity, iu consequence of any slight excitement or disturbance. If this 
red discharge continues for any undue length of time, there is reason 
to suspect some abnormality, and it may not unfrequently be traced to 
slight lacerations about the cervix, Avhich have not healed properly. 
This result may also follow premature exertion, interfering with the 
proper involution of the uterus ; and the patient should certainly not be 
allowed to move about as long as much colored discharge is going on. 

Occasionally the lochia have an intensely fetid odor. This must 
always give rise to some anxiety, since it often indicates the retention 
and putrefaction of coagula, and involves the risk of septic absorption. 
It is not very rare, however, to observe a most disagreeable odor per- 
sist in the lochia without any bad results. The fetor always deserves 
careful attention, and an endeavor should be made to obviate it by 
directing the nurse to syringe out the vagina freely night and morning 
with creolin and water; while, if it be associated with quickened 
pulse and elevated temperature, other measures, to be subsequently 
described, will be necessary. 

The after-pains, which many child bearing women dread even more 
than the labor pains, are irregular contractions occurring for a vary- 
ing time after delivery, and resulting from the efforts of the uterus to 
expel coagula which have formed in its interior. If, therefore, special 
care be taken to secure complete and permanent contraction after labor, 
they rarely occur, or to a very slight extent. Their dependence on 
uterine inertia is evidenced by the common observation that they are 
seldom met with in primiparse, in w T hom uterine contraction may be 
supposed to be more efficient, and are more frequent in women who 
have borne many children. They are a preventable complication, and 
one which need not give rise to any anxiety ; they are, indeed, rather 
salutary than the reverse ; for, if coagula be retained in utero, the 
sooner they are expelled the better. The after-pains generally begin 
a few hours after delivery, and continue in bad cases for three or four 
days, but seldom longer. They are generally increased when the 
mammae are irritated by suction. When at their height they are often 
relieved by the expulsion of the coagula. In some severe cases they 
are apparently neuralgic in character, and do not seem to depend on 
the retention of coagula. They may be readily distinguished from 
pains due to more serious causes, by feeling the enlarged uterus harden 
under their influence, by the uterus not being tender on pressure, and 
by the absence of any constitutional symptoms. 

The management of women after childbirth has varied much at 
different times, according to fashion or theory. The dread of inflam- 

1 Giles. " On the Lochia." Obst. Trans., vol. xxxv. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 565 

matiou long influenced the professional mind and caused the adoption 
of a strictly antiphlogistic diet, which led to a tardy convalescence. 
The recognition of the essentially physiological character of labor has 
resulted in more sound views, with manifest advantage to our patients. 
The main tacts to bear in mind with regard to the puerperal woman 
are : her nervous susceptibility, which necessitates quiet and absence of 
all excitement ; the importance of favoring involution by prolonged 
rest; and the risk of septicemia, which calls for perfect cleanliness 
and attention to hygienic precautions. 

As soon as we are satisfied that the uterus is perfectly contracted 
and that all risk of hemorrhage is over, the patient should be left to 
sleep. Many practitioners administer an opiate ; but as a matter of 
routine this is certainly not good practice, since it checks the contrac- 
tions of the uterus and often produces unpleasant effects. Still, if the 
labor have been long and tedious, and the patient be much exhausted, 
fifteen or twenty drops of Battley's solution may be administered with 
advantage. 

Within a few hours the patient should be seen, and at the first visit 
particular attention should be paid to the state of the pulse, the uterus, 
and the bladder. The pulse during the whole period of convalescence 
should be carefully watched, and, if it be at all elevated, the tempera- 
ture should at once be taken. If the pulse and temperature remain 
normal, we may be satisfied that things are going on well ; but if the 
one be quickened and the other elevated, some disturbance or compli- 
cation may be apprehended. The abdomen should be felt, to see that 
the uterus is not unduly distended and that there is no tenderness. 
After the first day or two this is no longer necessary. 

Treatment of Retention of Urine. — Sometimes the patient cannot 
at first void the urine, and the application of a hot sponge over the 
pubes may enable her to do so. If the retention of urine be due to 
temporary paralysis of the bladder, three or four 20-minim doses of 
the liquid extract of ergot, at intervals of half an hour, may prove 
successful. Many hours should not be allowed to elapse without 
relieving the patient by the catheter, since prolonged retention is only 
likely to make matters worse. In many cases the use of the catheter 
may be avoided by propping up the patient in the sitting posture, in 
which she is often able to micturate when she cannot do so lying, and 
this plan has the further advantage of allowing the lochia to drain 
awav from the vagina. It may be necessary, subsequently, to empty 
the bladder night and morning, until the patient regain her power 
over it, or until the swelling of the urethra subsides, and this will 
generally be the case in a few days. The utmost care should be taken 
to keep the catheter aseptic, and it should lie in a basin of 1 : 1000 
sublimate solution, otherwise its frequent use might lead to cystitis. 
Occasionally the bladder becomes largely distended, and is relieved to 
some degree by dribbling of urine from the urethra. Such a state of 
things may deceive the patient and nurse, and may produce eerious 
consequences. Attention to the condition of the abdomen will prevent 
the practitioner from being deceived, for in addition to some constitu- 
tional disturbance, a large, tender, and fluctuating swelling will be found 



566 THE PUERPERAL STATE. 

in the hypogastric region distinct from the uterus, which it displaces 
to one or other side. The catheter will at once prove that this is pro- 
duced by distention of the bladder. 

Treatment of Severe After-pains. — If the after-pains be very 
severe, an opiate may be administered, or, if the lochia be not over- 
abundant, a linseed-meal poultice, sprinkled with laudanum, or with 
the chloroform and belladonna liniment, may be applied. If proper 
care have been taken to induce uterine contraction, they will seldom 
be sufficiently severe to require treatment. In America quinine, in 
doses of 10 grains twice daily, has been strongly recommended, espe- 
cially when opiates fail and when the pains are neuralgic in character, 
and I have found this remedy answer extremely well. The quinine is 
best given in solution with 10 or 15 minims of hydrobromic acid, 
which materially lessens the unpleasant head symptoms often accom- 
panying the administration of such large doses. The inhalation of the 
nitrite of amyl in severe cases is said to be very efficacious. 1 

Diet and Regimen. — The diet of the puerperal patient claims 
careful attention, the more so as old prejudices in this respect are as 
yet far from exploded, and it is by no means rare to find mothers and 
nurses who still cling tenaciously to the idea that it is essential to 
prescribe a low regimen for many days after labor. The erroneous- 
ness of this plan is now so thoroughly recognized that it is hardly 
necessary to argue the point. There is, however, a tendency in some 
to err in the opposite direction, which leads them to insist on the 
patient's consuming solid food too soon after delivery and before she 
has regained her appetite, thereby producing nausea and intestinal 
derangement. Our best guide in this matter is the feelings of the 
patient herself. If, as is often the case, she be disinclined to eat, 
there is no reason why she should be urged to do so. A good cup of 
beef-tea, some bread and milk, or an egg beaten up with milk, may 
generally be given with advantage shortly after delivery, and many 
patients are not inclined to take more for the first day or so. If the 
patient be hungry there is no reason why she should not have some 
more solid, but easily digested food, such as white fish, chicken, or 
sweetbread ; and, after a day or two, she may resume her ordinary diet, 
bearing in mind that, being confined to bed, she cannot with advan- 
tage consume the same amount of solid food as when she is up and 
about. Dr. Oldham, in his presidential address to the Obstetrical 
Society, 2 made some apposite remarks on this point which are worthy 
of quotation : " A puerperal month under the guidance of a monthly 
nurse is easily drawn out, and it is well if a love of the comforts of 
illness and the persuasion of being delicate, which are the infirmities 
of many women, do not induce a feeble life which long survives after 
the occasion of it is forgotten. I know no reason why, if a woman is 
confined early in the morning, she should not have her breakfast of 
tea and toast at nine, her luncheon from some digestible meat at one, 
her cup of tea at five, her dinner with chicken at seven, and her tea 
again at nine, or the equivalent, according to the variation of her 

1 Mr. F. W. Kendle : Lancet, vol. i. p. 600. 2 Obst. Trans., 1865, vol. v. p. 14. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 567 

habits of living. Of course there is the coinmon-sense selection of 
articles of food, guarding against excess, and avoiding stimulants. 
But gruel and slops and all intermediate feeding are to be avoided." 
]STo one who has seen both methods adopted can fail to have been 
struck with the more rapid and satisfactory convalesrnce which takes 
place when the patient's strength is not weakened by an unnecessarily 
low diet. Stimulants, as a rule, are not required ; but if the patient be 
weakly and exhausted, or if she be accustomed to their use, there can 
be no reasonable objection to their judicious administration. 

Attention to Cleanliness. — Immediately after delivery a warm 
napkin or pad of aseptic wool is applied to the vulva, and after the 
patient has rested a little, the nurse removes the soiled linen from the 
bed and washes the external genitals. It is impossible to pay too 
much attention during the subsequent progress of the case to the main- 
tenance of perfect cleanliness. Perfectly antiseptic midwifery is no 
doubt an impossibility, but a near approach to it may be made, and 
the greater the care taken the more certainly will the safety of the 
patient be insured. 1 It will be a wise precaution to advise the nurse 
never to touch the genitals for the first few days, unless her hands 
have been moistened in a 1 : 20 solution of carbolic acid, or 1 : 1000 
solution of perchloride of mercury, or lubricated with carbolized 
vaseline. The linen should be frequently changed, and all dirty linen 
and discharges immediately removed from the apartment. The vulva 
should be washed daily with a solution of perchloride of mercury of 
the strength of 1 : 2000, or with creolin and water, and the patient 
will derive great comfort from having the vagina gently syringed 
out once a day with the latter solution. Systematic douching of the 
vagina has been found prejudicial in lying-in hospitals, but in private 
practice, used as here advised, I am quite satisfied of its utility. The 
remarkable diminution of mortality which has followed such anti- 
septic precautions in lying-in hospitals well shows the importance of 
these measures. The room should be kept tolerably cool, and fresh 
air freely admitted. 

Action of the Bowels. — It is customary, on the morning of the 
second or third day, to secure an action of the bowels ; and there is no 
better way of doing this than by a large enema of soap and water. If 

1 I distribute the following rules to the monthly nurses attending my own patients, with the 
Tesult, I believe, of a marked improvement in their comfort and a more generally satisfactory con- 
valescence. 

ANTISEPTIC RULES FOR MONTHLY NURSES. 

1. Two bottles are supplied to each patient. One contains a mixture of perchloride of mercury, 
of the strength of 1 part to 1000 of water (called the 1:1000 solution], the other carbolized 
vaseline (1:8). 

2 A small basin containing the 1 : 1000 solution must always stand by the bedside of the patient, 
and the nurse, having first washed her hands in soap and water, must thoroughly rinse them in it 
every time she touches the patient in the neighborhood of the genital organs, for washing or any 
other purpose whatsoever, before or during labor, and for a week after delivery. 

3. Pledgets of cotton-wool should be used for washing the genitals instead of sponges. 

4. Vaginal and rectal pipes, catheters, etc., must be dipped in the 1 : 1000 solution before being 
used. The surfaces of slippers, bedpans, etc., should also be sponged with it. 

5. Vaginal pipes, enema-tubes, catheters, etc., should be smeared with the carbolized vaseline 
before use. 

6. Unless express directions are given to the contrary, the vagina should be syringed once daily 
afte" delivery with warm water with sufficient creolin dropped into it to give it a milky hue. 

7. All soiled linen, diapers, etc., should be immediately removed from the bedroom. 

N. B.— These rules are for the purpose of protecting the patient from the risk arising from acci- 
dental contamination of the hands, etc. It is, therefore, hoped that they will be faithfully and 
minutelv adhered to. 



568 THE PUERPERAL STATE. 

the patient object to this, and the bowels have not acted, some mild 
aperient may be administered, such as a small dose of castor oil, a few 
grains of colocynth and henbane pill, or the popular French aperient, 
the " Tamar Indien." 

Lactation. — The management of suckling and of the breasts forms 
an important part of the duties of the monthly nurse, which the prac- 
titioner should himself superintend. This will be more conveniently 
discussed under the head of lactation. 

Importance of Prolonged Rest. — The most important part of the 
management of the puerperal state is the securing to the patient pro- 
longed rest in the horizontal position, in order to favor proper involu- 
tion of the uterus. For the first few days she should be kept as quiet 
and still as possible, not receiving the visits of any but her nearest 
relatives, thus avoiding all chance of undue excitement. It is cus- 
tomary among the better classes for the patient to remain in bed for 
eight or ten days ; but, provided she be doing well, there can be no 
objection to her lying on the outside of the bed, or slipping on to a 
sofa, somewhat sooner. After ten days or a fortnight she may be 
permitted to sit on a chair for a little, but I am convinced that the 
longer she can be persuaded to retain the recumbent position, the 
more complete and satisfactory will be the progress of involution ; and 
she should not be allowed to walk about until the third week, about 
which time she may also be permitted to take a drive. If it be borne 
in mind that it takes from six weeks to two months for the uterus to 
regain its natural size, the reason for prolonged rest will be obvious. 
The judicious practitioner, however, while insisting on this point, will 
take measures at the same time not to allow the patient to lapse into the 
habits of an invalid, or to give the necessary rest the semblance of disease. 

Subsequent Treatment. — Toward the termination of the puer- 
peral month some slight tonic, such as small doses of quinine with 
phosphoric acid, may be often given with advantage, especially if con- 
valescence be tardy. Nothing is so beneficial in restoring the patient 
to her usual health as change of air, and in the upper classes a short 
visit to the seaside may generally be recommended, with the certainty 
of much benefit. 



CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of Respiration. — Almost immediately after its 
expulsion, a healthy child cries aloud, thereby showing that respiration 
is established, and this may be taken as a signal of its safety. The 
first respiratory movements are excited, partially by reflex action 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 569 

resulting from the contact of the cold external air with the cutaneous 
nerves, and partly by the direct irritation of the medulla oblongata, 
in consequence of the circulation through it of blood no longer 
oxygenated in the placenta. 

Apparent Death of the Newborn Child. — Not unfrequently the 
child is born in an apparently lifeless state. This is especially likely 
to be the case when the second stage of labor has been unduly pro- 
longed, so that the head has been subjected to long-continued pressure. 
The utero-plaeental circulation is also apt to be injuriously interfered 
with before the birth of the child when a tardy labor has produced 
tonic contraction of the uterus, and consequent closure of the uterine 
sinuses; or, more rarely, from such causes as the injudicious adminis- 
tration of ergot, premature separation of the placenta, or compression 
of the umbilical cord. In any of these cases it is probable that the 
arrest of the utero-placental circulation induces attempts at inspira- 
tion, which are necessarily fruitless, since air cannot reach the lungs, 
and the foetus may die asphyxiated ; the existence of the respiratory 
movement being proved on post-mortem examination by the presence 
in the lungs of liquor amnii, mucus, and meconium, and by the 
extravasation of blood from the rupture of their engorged vessels. 

In most cases, when the child is born in a state of apparent asphyxia, 
its face is swollen and of a dark livid color. It not infrequently 
makes one or two feeble and gasping efforts at respiration without any 
definite cry ; on auscultation the heart may be heard to beat weakly 
and slowly. Under such circumstances there is a fair hope of its 
recoverv. Iu other cases the child, instead of being; turgid and livid 

. too 

in the face, is pale, with flaccid limbs, and no appreciable cardiac 
action ; then the prognosis is much more unfavorable. 

Treatment of Apparent Death. — No time should be lost in 
endeavoring to excite respiration, and, at first, this must be done by 
applying suitable stimulants to the cutaneous nerves, in the hope of 
exciting reflex action. The cord should be at once tied, and the child 
removed from the mother ; for the final uterine contractions have so 
completely arrested the utero-placental circulation as to render it no 
longer of any value. If the face be very livid, a few drops of blood 
may with advantage be allowed to flow from the cord before it is tied, 
with the view of relieving the embarrassed circulation. Very often 
some slight stimulus, such as one or two sharp slaps on the thorax, or 
rapidly rubbing the body with brandy poured into the palms of the 
hands, will suffice to induce respiration. Failing this, nothing acts so 
well as the sudden and instantaneous application of heat and cold. 
For this purpose extremely hot water is placed in one basin, and 
quite cold water in another. Taking the child by the shoulders and 
legs, it should be dipped for a single moment into the hot water, and 
then into the cold; and these alternate applications may be repeated 
once or twice, as occasion requires. The effect of this measure is often 
very marked, and I have frequently >vcn it succeed when prolonged 
efforts at artificial respiration have been made in vain. 

If these means fail, an endeavor must be at once made to cany on 
respiration artificially. The best means of doing this have been ex- 



570 THE PUERPERAL STATE. 

haustively studied by Dr. Champneys, 1 who considers the only two 
reliable means of carrying on artificial respiration are those of Schultze 
and Sylvester. The Sylvester method is, on the whole, that which is 
most easily applied, and, on account of the compressibility of the 
thorax, it is peculiarly suitable for infants. The child being laid on 
its back, with the shoulders slightly elevated and the feet held in an 
elongated position by an assistant, the elbows are grasped by the 
operator, and alternately raised above the head, and slowly depressed 
against the sides of the thorax, being at the same time everted, so as 
to produce the effect of inspiration and expiration. In Schultze's 
method the child is grasped on either side of the thorax, the operator's 
thumbs being anterior, the index fingers being in the axillae, and the 
remaining fingers on the child's back. The operator's arms are now 
stretched out so that the child hangs at arm's length between his knees. 
By this means the chest is expanded, and inspiratory movements are 
produced. The operator's arms are now swung upward until they 
are horizontal. This causes the child's body to be flexed, its head is 
directed downward, and its legs fall toward the operator until the 
weight of its body rests on his thumbs. By this means its thorax and 
abdomen are compressed, its diaphragm is forced upward, and expira- 
tion results. If now the child be again swung into its former position, 
inspiration follows. 

Other means of exciting respiration have been recommended. One 
of them, much used abroad, is the artificial insufflation of the lungs 
by means of a flexible catheter guided into the glottis, or by placing 
a handkerchief over the child's mouth and directly insufflating the 
lungs. It is not difficult to pass the end of a catheter into the glottis, 
using the little finger as a guide ; and once in position, it may be used 
to blow air gently into the lungs, which is expelled by compression on 
the thorax, the insufflation being repeated at short intervals of about 
ten seconds. One advantage of this plan is that it allows the liquor 
amnii and other fluids, which may have been drawn into the lungs in 
the premature efforts at respiration before birth, to be sucked up into 
the catheter, and so removed from the lungs. Dr. Champneys recom- 
mends that when the catheter is passed into the trachea for about three 
inches from the child's mouth, the thorax should be gently compressed, 
and then air should be blown through the catheter. The effect of this 
manoeuvre is that any mucus or fluids in the trachea pass upward 
through the glottis into the pharynx. The same effect may be pro- 
duced, but less perfectly, by placing the hand over the nostrils of the 
child, blowing into its mouth, and immediately afterward compressing 
the thorax. One of these methods should certainly be tried if all 
other means have failed. Faradization along the course of the phrenic 
nerve is a promising means of inducing respiration, which should be 
used if the proper apparatus can be procured. Encouragement to 
persevere in our endeavors to resuscitate the child may be derived 
from the numerous authenticated instances of success after the lapse 
of a considerable time, even of an hour or more. As long as the 

i Medico-Chir. Trans., vol. lxiv. pp. 41, 87 and vol. lxv. p. 75. 



571 

cardiac pulsations continue, however feebly, there is no reason to 
despair, and Champnevs has collected some apparently authenticated 
cases in which children seemingly dead have been buried for some 
hours and then dug up and restored to life. 

Washing- and Dressing- of the Child. — When the child cries 
lustily from the first, it is customary for the nurse to wash and dress 
it as soon as her immediate attendance on the mother is no longer 
required. For this purpose it is placed in a bath of warm water, and 
carefully soaped and sponged from head to foot. With the view of 
facilitating the removal of the unctuous material with which it is 
covered, it is usual to anoint it with cold cream or olive oil, which is 
washed off in the bath. JSurses are apt to use undue roughness in 
endeavoring to remove every particle of the vernix caseosa, small 
portions of which are often firmly adherent. This mistake should be 
avoided, as these particles will soon dry up and become spontaneously 
detached. The cord is generally wrapped in a small piece of charred 
linen, which is supposed to have some slight antiseptic property, and 
this is renewed from day to day until the cord has withered and sepa- 
rated. This generally occurs within a week ; and a small pad of soft 
linen is then placed over the umbilicus, and supported by a flannel 
belly-band placed around the abdomen, which should not be too tight, 
for fear of embarrassing the respiration. By this means the tendency 
to umbilical hernia is prevented. 

The clothing of the infant varies according to fashion and the 
circumstances of the parents. The important points to bear in mind 
are that it should be warm (since newly-born children are extremely 
susceptible to cold), and at the same time light and sufficiently loose 
to allow free play to the limbs and thorax. All tight bandaging and 
swaddling, such as is so common in some parts of the Continent, 
should be avoided, and the clothes should be fastened by strings or by 
sewing, no pins being used. At the present day it is customary not to 
use caps, so that the head may be kept cool. The utmost possible 
attention should be paid to cleanliness, and the child should be regu- 
larly bathed in tepid water, at first once daily, and after the first few 
weeks, both night and morning. After drying, the flexures of the 
thighs and arms, and the nates, should be dusted with violet powder 
or fuller's earth, to prevent chafing of the skin. The excrements 
should be received in napkins wrapped around the hips, and great 
care is required to change the napkins as often as they are wet or 
soiled, otherwise troublesome irritation will arise. A neglect of this 
precaution, and the washing of the napkins with coarse soap or soda, 
are among the principal causes of the eruptions and excoriations so 
common in badly -cared -for children. When washed and dressed the 
child may be placed in its cradle, and covered with soft blankets or an 
eider-down quilt. 

As soon as the mother has rested a little, it is advisable to place the 
child to the breast. This is useful to the mother by favoring uterine 
contraction. Even now there is in the breasts a variable quantity of 
the peculiar fluid known as colostrum. This is a viscid yellowish 
secretion, different in appearance from the thin bluish milk which is 



572 THE PUERPERAL STATE. 

subsequently formed. Examined under the microscope it is found to 
contain some milk-globules and a number of large granular and 
small fat corpuscles. It has a purgative property, and soon produces, 
with less irritation than any of the laxatives so generally used, a dis- 
charge of the meconium with which the bowels are loaded. Hence 
the accoucheur should prohibit the common practice of administering 
castor oil, or other aperient, within the first few days after birth, 
although there can be no objection to it in special cases, if the bowels 
appear to act inefficiently and with difficulty. 

Over-frequent Suckling" should be Avoided. — For the first few 
days, and until the secretion of milk is thoroughly established, the 
child should be put to the breast at long intervals only. Constant 
attempts at suckling an empty breast lead to nothing but disappoint- 
ment, both to the mother and child, and, by unduly irritating the 
mamma?, sometimes do positive harm. Therefore, for the first day or 
two, it is sufficient if the child be applied to the breast twice, or at 
most three times, in the twenty-four hours. Nor is it necessary to be 
apprehensive, as many mothers naturally are, that the child will suffer 
from want of food. A few spoonfuls of milk and water being given 
from time to time, the child may generally wait without injury until 
the milk is secreted. This is generally about the third clay, when the 
secretion is found to be a whitish fluid, more watery in appearance 
than cow's milk, and showing under the microscope an abundance of 
minute spherical globules, refracting light strongly, which are abun- 
dant in proportion to the quality of the milk. A certain number of 
granular corpuscles may also be observed shortly after the birth of the 
child, but after the first month these should have almost or altogether 
disappeared. The reaction of human milk is decidedly alkaline, and 
the taste much sweeter than that of cow's milk. 

The importance to the mother of nursing her own child, whenever 
her health permits, on account of the favorable influence of lactation 
in promoting a proper involution of the uterus, has already been in- 
sisted on. Unless there be some positive contra-indication, such as a 
marked strumous cachexia, an hereditary phthisical tendency, or great 
general debility, it is the duty of the accoucheur to urge the mother to 
attempt lactation, even if it be not carried on more than a month or 
two. It is, however, the fact that in the upper classes of society a 
large number of patients are unable to nurse, even though willing 
and anxious to do so. In some there is hardly any lacteal secretion 
at all, in others there is at first an over-abundance of watery and in- 
nutritious milk, which floods the breasts and soon dies away alto- 
gether. Something analogous to this result of breeding and culture is 
observed in the lower animals. Thus in the so-called "pedigree" 
cattle, the cow is never able to nurse its calf; and the same is observed, 
though less constantly, in thoroughbred racing stock. 

"When the Mother cannot Nurse, a Wet-nurse should be Pro- 
cured. — Whenever the mother cannot or will not nurse, the question 
will arise as to the method of bringing up the child. From many 
causes there is an increasing tendency to resort to bottle-feeding, in- 
stead of procuring the services of a wet-nurse, even when the question 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 573 

of expense does not come into consideration. No long experience is 
required to prove that hand-feeding is a bad and imperfect substitute 
for Nature's mode, and one which the practitioner should discourage 
whenever it lies in his power to do so. It is true that, in many cases, 
bottle-fed children do well; but there is good reason to believe that, 
even when apparently most successful, the children are not so strong 
in after life as they would have been had they been brought up at the 
breast. When, in addition, it is borne in mind how much of the 
success of hand-feeding depends on intelligent care on the part of the 
nurse, what evils are apt to accrue from the injudicious selection of 
food, and from ignorance of the commonest laws of dietetics, there is 
abundant reason for urging the substitution of a wet-nurse whenever 
the mother is unable to undertake the suckling of her child. It must 
be admitted that good hand-feeding is better than bad wet-nursing, 
and the success of the latter hinges on the proper selection of a wet- 
nurse. As this falls within the duties of the practitioner, it will be 
well to point out the qualities which should be sought for in a wet- 
nurse, before proceeding to discuss the mode of rearing the child at 
the breast. 

Selection of a Wet-nurse. — In selecting a wet-nurse we should 
endeavor to choose a strong, healthy woman, who should not be over 
thirty or thirty-five years of age at the outside, since the quality of 
the milk deteriorates in women who are more advanced in life. For 
a similar reason a very young woman of sixteen or seventeen should 
be rejected. It is needless to say that care must be taken to ascertain 
the absence of all traces of constitutional disease, especially marks of 
scrofula, or enlarged cervical or inguinal glands, which may possibly 
be due to antecedent syphilitic taint. If the nurse be of good mus- 
cular development, healthy-looking, with a clear complexion, and 
sound teeth (indicating a generally good state of health), the color of 
the hair and eyes is of secondary importance. It is commonly stated 
that brunettes make better nurses than blondes, but this is by no 
means necessarily the case; and provided all the other points be favor- 
able, fairness of skin and hair need be no bar to the selection of a 
nurse. The breasts should be pear-shaped, rather firm, as indicating 
an abundance of gland-tissue, and with the superficial veins well 
marked. Large, flabby breasts owe much of their size to an undue 
deposit of fat, and are generally unfavorable. The nipple should be 
prominent, not too large, and free from cracks and erosions, which, if 
existing, might lead to subsequent difficulties in nursing. On press- 
ing the breast the milk should flow from it easily in a number of 
small jets, and some of it should be preserved for examination. It 
should be of a bluish-white color, and when placed under t\\a micro- 
scope the field should be covered with an abundance of milk corpus- 
cles, and the large granular corpuscles of the colostrum should have 
entirely disappeared. If the latter be observed in any quantity in a 
woman who has been confined five or six week-, the inference is that the 
milk is inferior in quality. It is not often that the practitioner has an 
opportunity of inquiring into the moral qualities of the nurse, although 
much valuable information might be derived from a knowledge of her 



574 THE PUERPERAL STATE. 

previous character. An irasciole, excitable, or highly nervous woman 
will certainly make a bad nurse, and the most trivial causes might 
afterward interfere with the quality of her milk. Particular attention 
should be paid to the nurse's own child, since its condition affords the 
best criterion of the quality of her milk. It should be plump, well- 
nourished, and free from all blemishes. If it be at all thin and 
wizened, especially if there be any snuffling at the nose, or should any 
eruption exist affording the slightest suspicion of a syphilitic taint, the 
nurse should be unhesitatingly rejected. 

Management of Suckling-. — The management of suckling is much 
the same whether the child is nursed by the mother or by a wet- 
nurse. As soon as the supply of milk is sufficiently established, the 
child must be put to the breast at short intervals, at first of about two 
hours, and, in about a month or six weeks, of three hours. From 
the first few days it is a matter of the greatest importance, both to the 
mother and child, to acquire regular habits in this respect. If the 
mother gets into the way of allowing the infant to take the breast 
whenever it cries, as a means of keeping it quiet, her own health must 
soon suffer, to say nothing of the discomfort of being incessantly tied 
to the child's side ; while the child itself has not sufficient rest to 
digest its food, and very shortly diarrhoea or other symptoms of 
dyspepsia are pretty sure to follow. After a month or two the infant 
should be trained to require the breast less often at night, so as to 
enable the mother to have an undisturbed sleep of six or seven hours. 
For this purpose she should arrange the times of nursing so as to give 
the breast just before she goes to bed, and not again until the early 
morning. If the child should require food in the interval, a little 
milk in water, from the bottle, may be advantageously given. 

Diet of Nursing Women. — The diet of the nursing woman should 
be arranged on ordinary principles of hygiene. It should be abundant, 
simple, and nutritious, but all rich and stimulating articles of food 
should be avoided. A common error in the diet of wet-nurses is over- 
feeding, which constantly leads to deterioration of the milk. Many 
of these women, before entering on their functions, have been living 
on the simplest and even sparest diet, and not uncommonly, in the 
better class of houses, they are suddenly given heavy meat meals three 
and even four times a day, and often three or four glasses of stout. It 
is hardly a matter of astonishment that, under such circumstances, 
their milk should be found to disagree. For a nursing woman in good 
health two good meat meals a day, with two glasses of beer or porter, 
and as much milk and bread-and-butter as she likes to take in the 
intervals, should be amply sufficient. Plenty of moderate exercise 
should be taken, and the more the nurse and child are out in the open 
air, provided the weather be reasonably fine, the better it is for both. 

Signs of Successful Lactation. — Carried on methodically in this 
manner, wet-nursing should give but little trouble. In the intervals 
between its meals the child sleeps most of its time, and wakes with 
regularity to feed ; but if the child be wakeful and restless, cry after 
feeding, have disordered bowels, and, above all, if it do not gain, week 
by week, in weight (a point which should be, from time to time, ascer- 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 575 

taiued by the scales), we may conclude that there is either some grave 
defect in the management of suckling, or that the milk is not agreeing. 

Should this unsatisfactory progress continue, in spite of our endeavors 
to remedy it, there is no resource left but the alteration of the diet, 
either by changing the nurse or by bringing Tip the child by hand. 
The former should be preferred whenever it is practicable, and in the 
upper ranks of life it is by no means rare to have to change the wet- 
nurse two or three times before one is met with whose milk agrees 
perfectly. If the child have reached six or seven months of age, it 
may be preferable to wean it altogether, especially if the mother has 
nursed it, as hand-feeding is much less objectionable if the infant has 
had the breast for even a few months. 

Period of "Weaning-. — As a rule, weaning should not be attempted 
until dentition is fairlv established, that beings the sum that Nature has 
prepared the child for an alteration of food ; and it is better that the 
main portion of the diet should be breast milk until at least six or 
seven teeth have appeared. This is a safer guide than any arbitrary 
rule taken from the age of the child, since the commencement of den- 
tition varies much in different cases. About the sixth or seventh 
month it is a good plan to commence the use of some suitable artificial 
food once a day, so as to relieve the strain on the mother or nurse, and 
prepare the child for weaning, which should always be a very gradual 
process. In this way a meal of rusks of entire wheat-flour, or of beef- 
or chicken-tea, with bread-crumb in it, may be given with advantage ; 
and as the period for weaning arrives a second meal may be added, 
and so eventually the child may be weaned without distress to itself or 
trouble to the nurse. 

The disorders of lactation are numerous, and as they frequently 
come under the notice of the practitioner, it is necessary to allude to 
some of the most common and important. 

Means of Arresting- the Secretion of Milk. — The advice of the 
accoucheur is often required in cases in which it lias been determined 
that the patient is not to nurse, when we desire to get rid of the milk 
as soon as possible, or when, at the time of weaning, the same object is 
sought. The extreme heat and distention of the breasts, in the former 
class of cases, often give rise to much distress. A smart saline aperient 
will aid in removing the milk, and for this purpose a double Seidlitz 
powder, or frequent small doses of sulphate of magnesia, act well ; 
while, at the same time, the patient should be advised to take as small 
a quantity of fluid as possible. Iodide of potassium in large doses of 
twenty or twenty-five grains, repeated twice or thrice, lias a remarkable 
effect in arresting the secretion of milk. This observation was first 
empirically made by observing that the secretion of milk was arrested 
when this drug was administered for some other cause ; and I have 
frequently found it answer remarkably well. The distention of the 
breasts is best relieved by covering them with a layer of lint or cotton- 
wool, soaked in a spirit lotion or can de Cologne and water, over which 
oiled silk is placed, and by directing the nurse to rub them gently with 
warm oil, whenever they get hard and lumpy. Breast-pumps and 
similar contrivances only irritate the breasts, and do more harm than 



576 THE PUERPERAL STATE. 

good. The local application of belladonna has been strongly recom- 
mended as a means for preventing lacteal secretion. As usually 
applied, in the form of belladonna plaster, it is likely to prove hurtful, 
since the breast often enlarges after the plasters are applied, and the 
pressure of the unyielding leather on which they are spread produces 
intense suffering. A better way of using it is by rubbing doAvn a 
drachm of the extract of belladonna with an ounce of glycerin, and 
applying this on lint. In some cases it answers extremely well ; but 
it is very uncertain in its action, and frequently is quite useless. 

Defective Secretion of Milk. — A deficiency of milk in nursing- 
mothers is a very common source of difficulty. In a wet-nurse this 
drawback is, of course, an indication for changing the nurse ; but to 
the mother the importance of nursing is so great that an endeavor 
must be made either to increase the flow of milk or to supplement it 
by other food. Unfortunately, little reliance can be placed on any of 
the so-called galactagogues. The only one which in recent times has 
attracted attention is the leaves of the castor-oil plant, which, made 
into poultices and applied to the breast, are said to have a beneficial 
effect in increasing the flow of milk. More reliance may be placed in 
a sufficiency of nutritious food, especially such as contains phosphatic 
elements ; stewed eels, oysters, and other kinds of shell-fish, and the 
Revalenta Arabica, are recommended by Dr. Routh, who has paid some 
attention to this point, 1 as peculiarly appropriate. If the amount of 
milk be decidedly deficient, the child should be less often applied to 
the breast, so as to allow milk to collect, and properly prepared cow's 
milk from a bottle should be given alternately with the breast. This 
mixed diet generally answers well, and is far preferable to pure hand- 
feeding. 

Depressed Nipples. — A not uncommon source of difficulty is a 
depressed condition of the nipples, which is generally produced by the 
constant pressure of the stays. The result is that the child, unable to 
grasp the nipple, and wearied with ineffectual efforts, may at last refuse 
the breast altogether. An endeavor should be made to elongate the 
nipple before putting it into the child's mouth, either by the fingers or 
by some form of breast-pump, which here finds a useful application. 
In the worst class of cases, when the nipple is permanently depressed, 
it may be necessary to let the child suck through a glass nipple-shield, 
to which is attached an India-rubber tube similar to that of a sucking- 
bottle ; this it is generally well able to do. 

Fissures and Excoriations of the Nipples. — Fissures and excoria- 
tions of the nipples are common causes of suffering, in some cases 
leading to mammary abscess. Whenever the practitioner has the 
opportunity, he should advise his patient to prepare the nipple for 
nursing in the latter months of pregnancy ; and this may best be done 
by daily bathing it with a spirituous or astringent lotion, such as eau 
de Cologne and water or a weak solution of tannin. After nursing 
lias begun great care should be taken to wash and dry the nipple after 
the child has been applied to it, and, as long as the mother is in the 

1 Routh on Infant- feeding. 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 577 

recumbent position, she may, if the nipples be at all tender, use zinc 
nipple-shields with advantage when she is not nursing. In this way 
these troublesome complications may generally be prevented. The 
most common forms are either an abrasion on the surface of the nipple, 
which, if neglected, may form a small ulcer, or a crack at some part 
of the nipple, most generally at its base. In either case, the suffering 
when the child is put to the breast is intense, sometimes indeed amount- 
ing to intolerable anguish, causing the mother to look forward with 
dread to the application of the child. Whenever such pain is com- 
plained of, the nipple should be carefully examined, since the fissure 
or sore is often so minute as to escape superficial examination. The 
remedies recommended are very numerous and not always successful. 
Amongst those most commonly used are astringent applications, such 
as tannin or weak solutions of nitrate of silver, or cauterizing the 
edges of the fissure with solid nitrate of silver, or applying the flexible 
collodion of the Pharmacopoeia. Dr. Wilson, of Glasgow, speaks 
highly of a lotion composed of ten grains of nitrate of lead in an 
ounce of glycerin, which is to be applied after suckling, the nipple 
being carefully washed before the child is again put to the breast. I 
have myself found nothing answer so well as a lotion composed of 
half an ounce of sulphurous acid, half an ounce of the glycerin of 
tannin, and an ounce of water, the beneficial effects of which are some- 
times quite remarkable. Relief may occasionally be obtained by 
inducing the child to suck through a nipple-shield, especially when 
there is only an excoriation ; but this will not always answer, on 
account of the extreme pain which it produces. 

Excessive Flow of Milk. — An excessive flow of milk, known as 
galactorrhcea, often interferes with successful lactation. It is by no 
means rare in the first weeks after delivery for women of delicate con- 
stitutions who are really unfit to nurse, to be flooded with a super- 
abundance of watery and innutritions milk, which soon produces 
disordered digestion in the child. Under such circumstances the only 
thing to be done is to give up an attempt which is injurious both to 
the mother and child. At a later stage the milk, secreted in large 
quantities, is sufficiently nourishing to the child, but the drain on the 
mother's constitution soon begins to tell on her. Palpitation, giddi- 
ness, emaciation, headache, loss of sleep, spots before the vyc±, indicate 
the serious effects which are being produced, and the absolute necessity 
of at once stopping lactation. Whenever, therefore, a nursing-woman 
suffers from such symptoms, it is far better at once to remove the 
cause, otherwise a very serious and permanent deterioration of health 
might result. When, under such circumstances, nursing is unwisely 
persevered in, most serious results may follow. Should any diathetic 
tendency exist, especially when there is a predisposition to phthisis, 
nothing is so likely to develop it as the debility produced by excessive 
lactation. Certain diseases of the eye are then specially apt to occur, 
such as severe inflammation of the cornea, leading to opacity and cv< a 
slouching, and certain forms of choroiditis; also impairment of accom- 
modation due to defective power of the ciliary muscle. 

Mammary Abscess. — There is no more troublesome complication 



578 THE PUERPERAL STATE. 

of lactation than the formation of abscess in the breast ; an occurrence 
by no means rare, and which, if improperly treated, may, by long- 
continued suppuration and the formation of numerous sinuses in and 
about the breast, produce very serious effects on the general health. 
The causes of breast abscesses are numerous, and very trivial circum- 
stances may occasionally set up inflammation ending in suppuration. 
Thus it may follow exposure to cold, a blow or other injury to the 
breast, some temporary engorgement of the lacteal tubes, or even 
sudden or depressing mental emotions. The most frequent cause is 
irritation from fissures or erosions of the nipple, which must there- 
fore always be regarded with suspicion and cured as soon- as possible. 

It has of late years been held that mammary abscess generally arises 
from septic infection through such fissures, an idea first suggested by 
Kaltenbach. Since that date pyogenic microbes have generally been 
detected in puerperal mammary abscesses. It is considered possible 
that infective microbes may find an entrance through the openings of 
the lactiferous ducts, when no fissures exist. 1 These considerations 
obviously point to the necessity of extreme care and cleanliness in all 
nursing- women. 

The abscess may form in any part of the breast, or in the areolar 
tissue below it ; in the latter case, the inflammation very generally 
extends to the gland structure. Abscess is usually ushered in by con- 
stitutional symptoms, varying in severity with the amount of the 
inflammation. Pyrexia is always present ; elevated temperature, rapid 
pulse, and much malaise and sense of feverishness, followed, in many 
cases, by distinct rigor, when deep-seated suppuration is taking place. 
On examining the breast it will be found to be generally enlarged and 
very tender, while at the site of the abscess an indurated and painful 
swelling may be felt. If the inflammation be chiefly limited to the 
sub-glandular areolar tissue, there may be no localized swelling felt, 
but the whole breast will be acutely sensitive and the slightest move- 
ment will cause much pain. As the case progresses, the abscess 
becomes more and more superficial, the skin covering it is red and 
glazed, and if left to itself it bursts. In the more serious cases it is 
by no means rare for multiple abscesses to form. These, opening one 
after the other, lead to the formation of numerous fistulous tracts, by 
which the breast may become completely riddled. Sloughing of por- 
tions of the gland tissue may take place, and even considerable hemor- 
rhage from the destruction of bloodvessels. The general health soon 
suffers to a marked degree, and, as the sinuses continue to suppurate 
for many successive months, it is by no means uncommon for the 
patient to be reduced to a state of profound and even dangerous 
debility. 

Treatment. — Much may be done by proper care to prevent the 
formation of abscess, especially by removing engorgement of the lacteal 
ducts, when threatened, by gentle hand-friction in the manner already 
indicated. When the general symptoms and the local tenderness 
indicate that inflammation has commenced, we should at once endeavor 

1 See Dr. J. Watt Black's Inaugural Address, Obstet. Trans., vol. xxxii. p. 97. 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 579 

to moderate it, in the hope that resolution may occur without the for- 
mation of pus. Here general principles must be attended to, especially 
giving the affected part as much rest as possible. Feverishness may 
be combated by gentle salines, minute doses of aconite, and large doses 
of quinine ; while pain should be relieved by opiates. The patient 
should be strictly confined in bed, and the affected breast supported by 
a suspensory bandage. Warmth and moisture are the best means of 
relieving the local pain, either in the form of hot fomentations or of 
light poultices of linseed-meal or bread and milk, and the breast may 
be smeared with extract of belladonna rubbed down with glycerin, or 
the belladonna liniment sprinkled over the surface of the poultices. 
The local application of ice in India-rubber bags has been highly ex- 
tolled as a means of relieving the pain and tension, and it is said to 
be much more effectual than heat and moisture. 1 Generally the pain 
and irritation produced by putting the child to the breast are so great 
as to contra-indicate nursing from the affected side altogether, and we 
must trust to relieving the tension by poultices ; suckling being, in the 
meantime, carried on at the other breast alone. In favorable cases 
this is quite possible for a time, and it may be that, if the inflammation 
do not end in suppuration, or if the abscess be small and localized, the 
affected breast is again able to resume its functions. Often this is not 
possible, and it may be advisable, in severe cases, to give up nursing 
altogether. 

The subsequent management of the case consists in the opening of 
the abscess as soon as the existence of pus is ascertained, either by 
fluctuation, or, if the site of the abscess be deep-seated, by the exploring- 
needle. It may be laid down as a principle, that the sooner the pus 
is evacuated the better, and nothing is to be gained by waiting until 
it is superficial. On the contrary, such delay only leads to more 
extensive disorganization of tissue, and the further spread of inflam- 
mation. 

The method of opening- the abscess is of primary importance. 
Care should be taken to make the incision in a line radiating from the 
nipple, so as to avoid cutting across the ducts. It has formerly been 
customary simply to open the abscess at its most dependent part, 
without using any precaution against the admission of air, and after- 
ward to treat secondary abscesses in the same way. The results are 
well known to all practical accoucheurs, and the records of surgery 
fully show how many weeks or months generally elapse in bad cases 
before recovery is complete. The antiseptic treatment of mammary 
abscess affords results which are of the most remarkable and satisfactory 
kind. Xot the least important part of the antiseptic treatment is the 
mechanical cleansing. This removes the greater part of the offending 
materials Instead of being weeks and months in healing, I believe 
that the practitioner who fairly and minutely carries out the principles 
of antiseptic surgery may confidently look for complete closure of the 
abscess in a few days; and I know nothing in the whole range of my 

1 Corson : Amer. Journ. of Obstet., vol. xiv. p. 48. 



580 THE PUERPERAL STATE. 

professional experience that has given me more satisfaction than the 
application of this method to abscesses of the breast. These are now 
so generally understood and practised that it is needless, as in former 
editions, to enter into details in this place. 

Treatment of Long-continued Suppuration. — If the case corn© 
under our care when the abscess has been long discharging, or when 
sinuses have formed, the treatment is directed mainly to procuring a 
cessation of suppuration and closure of the sinuses. For this purpose 
methodical strapping of the breast with adhesive plaster, so as to afford 
steady support and compress the opposing pyogenic surfaces, will give 
the best results. It may be necessary to lay open some of the sinuses, 
or to inject tinct. iodi or other stimulating lotions, so as to moderate 
the discharge, the subsequent surgical treatment varying according to 
the requirements of each case. In such neglected cases Billroth recom- 
mends that, after the patient has been anaesthetized, the openings 
should be dilated so as to admit the finger, by which the septa between 
the various sinuses should be broken down and a large single abscess- 
cavity made. This should then be thoroughly irrigated with a 3 per 
cent solution of carbolic acid, a drainage-tube introduced, and the 
ordinary antiseptic dressings applied. This advice I have followed in 
several cases of the kind, with the most beneficial result. As the drain 
on the system is great, and the constitutional debility generally pro- 
nounced, much attention must be paid to general treatment ; and abun- 
dance of nourishing food, appropriate stimulants, and such medicines 
as iron and quinine, will be indicated. 

Hand-feeding'. — In a considerable number of cases the inability of 
the mother to nurse her child, her invincible repugnance to a wet- 
nurse, or inability to bear the expense, renders hand-feeding essential. 
It is, therefore, of importance that the accoucheur should be thoroughly 
familiar with the best method of bringing up the child by hand, so as 
to be able to direct the process in the way that is most likely to be 
successful. 

Much of the mortality following hand-feeding may be traced to 
unsuitable food. Among the poorer classes especially there is a 
prevalent notion that milk alone is insufficient ; and hence the almost 
universal custom of administering various farinaceous foods, such as 
corn-flour or arrowroot, even from the earliest period. Many of these 
consist of starch alone, and are therefore absolutely unsuited for 
forming the staple of diet, on account of the total absence of nitro- 
genized elements. Independently of this, it has been shown that the 
saliva of infants has not the same digestive property on starch that 
it subsequently acquires, and this affords a further explanation of its 
so constantly producing intestinal derangement. Reason as well as 
experience abundantly proves that the object to be aimed at in hand- 
feeding is to imitate as nearly as possible the food which Nature sup- 
plies for the newborn child, and, therefore, the obvious course is to use 
milk from some animal, so treated as to make it resemble human milk 
as nearly as may be. 

Of the various milks used, that of the ass, on the whole, most closely 
resembles human milk, containing less casein and butter, and more 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 581 

saline ingredients. It is not always easy to obtain, and in towns it is 
excessively expensive. Moreover, it does not always agree with the 
child, being apt to produce diarrhoea. We can, however, be more 
certain of its being unadulterated, which in large cities is in itself no 
small advantage, and it may be given without the addition of water 
or sugar. 

Goat's milk in England is still more difficult to obtain, but it often 
succeeds admirably. In many places the infant sucks the teat directly, 
and certainly thrives well on this plan. 

Cow's Milk and its Preparation. — In a large majority of cases we 
have to rely on cow's milk alone. It differs from human milk in con- 
taining less water, a larger amount of casein and solid matters, and less 
sugar. Therefore, before being given it requires to be diluted and 
sweetened. A common mistake is over-dilution, and it is far from 
rare for nurses to administer one-third cow's milk to two-thirds water. 
The result of this excessive dilution is, that the child becomes pale and 
puny, and has none of the firm and plump appearance of a well-fed 
infant. The practitioner should, therefore, ascertain that this mistake 
is not being made ; and the necessary dilution will be best obtained by 
adding to pure fresh cow's milk one-third hot water, so as to warm 
the mixture to about 96°, the whole being slightly sweetened with 
sugar of milk or ordinary crystallized sugar. After the first two or 
three months the amount of water may be lessened, and pure milk a 
warmed aud sweetened, given instead. It is not now considered ueces- 
sary that the milk should be obtaiued from the same cow, but in towns 
some care is requisite to see that the animal is properly fed and stabled. 
Of late years it has been customary to obviate the difficulties of obtain- 
ing good fresh milk by using some of the canned milks now so easily 
to be had. These are already sweetened, aud sometimes answer well if 
not given in too weak a dilution, and they have the advantage of being 
practically sterilized in the process of preparation. One great drawback 
in bottle-feeding is the tendency of the milk to become acid, and hence 
to produce diarrhoea. This may be obviated to a great extent by 
adding a tablespoonful of lime-water to each bottle, instead of an equal 
quantity of water. 

Artificial Human Milk. — An admirable plan of treating cow's 
milk, so as to reduce it to almost absolute chemical identity with 
human milk, has been devised by Professor Franklaud, to whom I 
am indebted for permission to insert the recipe. I have followed this 
method in many cases, and find it far superior to the usual one, as it 
produces an exact and uniform compound. With a little practice 
nurses can make it with no more trouble than the ordinary mixing of 
cow's milk with water and sugar. The following extract from Dr. 
Frankland's work 1 will explain the principles on which the prepara- 
tion of the artificial human milk is founded : "The rearing of infants 
who cannot be supplied with their natural food is notoriously difficult 
and uncertain, owing chiefly to the great difference in the chemical 
composition of human milk and cow's milk. The latter is much richer 

i Franklanrt's Experimental Researches in Chemistry, p. 843. 



582 THE PUERPERAL STATE. 

in casein and poorer in milk-sugar than the former, whilst ass's milk, 
which is sometimes used for feeding infants, is too poor in casein and 
butter, although the proportion of sugar is nearly the same as in human 
milk. The relations of the three kinds of milk to each other are clearly 
seen from the following analytical numbers, which express the per- 
centage amounts of the different constituents : 

Woman. Ass. Cow. 

Casein 2.7 1.7 4.2 

Butter 3.5 1.3 3.8 

Milk-sugar . 5.0 4.5 3.8 

Salts .......... 0.2 0.5 0.7 

These numbers show that by the removal of one-third of the casein 
from cow's milk and the addition of about one-third more milk-sugar, 
a liquid is obtained which closely approaches human milk in composi- 
tion, the percentage amounts of the four chief constituents being as 
follows : 

Casein 2.8 

Butter 3.8 

Milk-sugar 5 

Salts 0.7 

The following is the mode of preparing the milk : Allow one-third of 
a pint of new milk to stand for about twelve hours, remove the cream, 
and to the latter add two-thirds of a pint of new milk, as fresh from 
the cow as possible. Into the one-third of a pint of blue milk left 
after the abstraction of the cream put a piece of rennet about one inch 
square. Set the vessel in warm water until the milk is fully curdled, 
an operation requiring from five to fifteen minutes according to the 
activity of the rennet, which should be removed as soon as the curdling 
commences and put into an egg-cup for use on subsequent occasions, 
as it may be employed daily for a month or two. Break up the curd 
repeatedly, and carefully separate the whole of the whey, which should 
then be rapidly heated to boiling in a small tin pan placed over a 
spirit or gas lamp. During the heating a further quantity of casein, 
technically called 'fleetings/ separates, and must be removed by 
straining through muslin. Now dissolve 110 grains of powdered 
sugar of milk in the hot whey, and mix it with the two-thirds of a 
pint of new milk to which the cream from the other third of a pint 
was added as already described. The artificial milk should be used 
within twelve hours of its preparation, and it is almost needless to 
add that all the vessels employed in its manufacture and administra- 
tion should be kept scrupulously clean." 1 

Method of Hand-feeding". — Much of the success of bottle-feeding 
must depend on minute care and scrupulous cleanliness, points which 
cannot be too strongly insisted on. Particular attention should be paid 
to preparing the food fresh for every meal, and to keeping the feeding- 
bottle and tubes constantly in water when not in use, so that minute 

1 The following recipe yields the same results, but the method is easier, and I find that nurses 
prepare the milk with less difficulty when it is followed: "Heat half a pint of skimmed milk to 
about 99°, that is, just warm, and well stir into the warmed milk a measure full of Walden's 
extract of rennet. When it is set, break up the °urd quite small, and let it stand for ten or fifteen 
minutes, when the curd will sink; then place the whey in a saucepan and boil quickly. In a third 
of a pint of this whey dissolve a heaped-up teaspoonful of sugar of milk. When quite cold, add two- 
thirds of a pint of new milk and two teaspoonfuls of cream, well stirring the whole together. If 
during the first month the milk is too rich, use rather more than a third of a pint of whey." 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 583 

particles of milk may not remain about them and become sour. A 
neglect of this is one of the most fertile sources of the thrush from 
which bottle-fed infants often suffer. The old boat-shaped bottle is 
preferable to those in common use which have a rubber tube attached. 
The former cau be perfectly and easily cleansed by immersion in boil- 
ing water, while in the latter minute portions of milk must necessarily 
remain iu the tube and tend to decompose. Care must be taken to give 
the meals at stated periods, as in breast-feeding, and these should be at 
first about two hours apart, the intervals being gradually extended. 
The nurse should be strictly cautioned against the common practice of 
placing the bottle beside the infant in its cradle and allowing it to suck 
to repletion — a practice which leads to over distention of the stomach 
and consequent dyspepsia. The child should be raised iu the arms at 
the proper time, have its food administered, and then replaced in the 
cradle to sleep. In the first few weeks of bottle-feeding constipation is 
very common, and may be effectually remedied by placing as much 
phosphate of soda as will lie on a threepenny-piece in the bottle, two 
or three times in the twenty-four hours. 

Sterilization of Milk. — The researches of Budin 1 and others have 
shown conclusively that much of the risk of hand-feeding depends on 
the presence of pathogenic organisms in the milk, which cause the 
digestive disturbance from which hand-fed infants are so apt to suffer. 
This risk can easily enough be met by treating the milk previous to 
use so as to sterilize it. 2 This can be effectively done by boiling it, 
which, however, has the disadvantage of coagulating and hardening the 
casein so as to render it less easily digestible. A better plan is to put 
the milk into one or more bottles placed in a saucepan, and surrounded 
by water which is kept at a temperature of 155° for not less than forty 

i Bullet, de l'Acad. de Med., 1893-94. 

- The accompanying woodcut (Fig. 195) represents a cheap and effective sterilizer. It contains 
seven bottles, each" holding sufficient for a meal, and forming a supply for twenty-four hours. 



Fig. 195. 




Hawksley's patent milk sterilizer. 



584 THE PUERPERAL STATE. 

minutes, the mouths of the bottles being plugged with medicated cotton 
wool until the milk is used. The boiling-point of milk (214°) being 
higher than that of water, the milk remains unboiled, even when the 
surrounding water reaches the boiling-point. Instrument makers now 
supply apparatus for nursery use to facilitate the process, but the 
method 1 have described can be improvised in every house, and by it 
the milk is perfectly purified. Budin states that when milk is so 
treated it is best given undiluted, but it can obviously be used in any 
of the ways previously described. 

The decrease in infant mortality which has accompanied perfect anti- 
sepsis in hand-feeding is very remarkable. This has specially been 
shown in the United States, where institutions for the supply of steril- 
ized milk have been established in many of the large cities. Huebner 1 
states that since 1896, when sterilized milk was introduced into the 
wards of the Charite Hospital in Berlin, the mortality has fallen from 
between 80 and 90 per cent, to 65 per cent, 

Other Kinds of Pood. — If this system succeed, no other food should 
be given until the child is six or seven months old, and then some of 
the various infants' foods may be cautiously commenced. Of these 
there are an immense number in common use, some of which are good 
articles of diet, others are unfitted for infants. In selecting them we 
have to see that they contain the essential elements of nutrition in 
proper combination. All those, therefore, that are purely starchy in 
character, such as arrowroot, corn-flour, and the like, should be 
avoided ; while those that contain nitrogenous as well as starch ele- 
ments may be safely given. Of the latter the entire wheat-flour, 
which contains the husks ground down with the wheat, generally 
answers admirably ; and of the same character are rusks, tops and 
bottoms, Nestle' s or Liebig's infants' food, and many others. If the 
child be pale and flabby, some more purely animal food may often be 
given twice a day, and great benefit may be derived from a single 
meal of beef, chicken, or veal tea, with a little bread-crumb in it, 
especially after the sixth or seventh month. Milk, however, should 
still form the main article of diet, and should continue to do so for 
many months. 

Management when Milk Disagrees. — If the child be pale, flabby, 
and do not gain flesh, more especially if diarrhoea or other intestinal 
disturbance be present, we may be certain that hand-feeding is not 
answering satisfactorily, and that some change is required. If the 
child be not too old, and will still take the breast, that is certainly 
the best remedy, but if that be not possible, it is necessary to alter the 
diet. When milk disagrees, sterilized cream, in the proportion of one 
tablespoonful to three of water, sometimes answers as well. Occasion- 
ally also Liebig's or Mellin's infants' food, when carefully prepared, 
renders good service. Too often, however, when once diarrhoea or 
other intestinal disturbance has set in, all our efforts may prove unavail- 
ing, and the health, if not the life, of the infant becomes seriously im- 
perilled. It is not, however, within the scope of this work to treat of 

1 Sauglingsernahrung und Sauglingsppitaler. Berlin, 1897. 



PUERPERAL ECLAMPSIA 585 

the disorders of infants at the breast, the proper consideration of which 
requires a large amount of space, and I therefore refrain from making 
any further remarks on the subject. 



CHAPTER III. 

PUERPERAL ECLAMPSIA. 

Puerperal Eclampsia. — By the term puerperal eclampsia is meant 
a peculiar kind of epileptiform convulsions, which may occur in the 
latter months of pregnancy, or during or after parturition, and it con- 
stitutes one of the most formidable diseases with which the obstetrician 
has to cope. The attack is often so sudden and unexpected, so terrible 
in its nature, and attended Avith such serious danger both to the 
mother and child, that the disease has attracted much attention. 

Its Doubtful Etiology. — The researches of Lever, Braun, Frerichs, 
and many other writers who have shown the frequent association of 
eclampsia with albuminuria, have of late years been supposed to 
clear up to a great extent the etiology of the disease and to prove its 
dependence on the retention of urinary elements in the blood. While 
the urinary origin of eclampsia has been pretty generally accepted, 
more recent observations have tended to throw doubt on its essential 
dependence on this cause ; so that it can hardly be said that we are 
yet in a position to explain its true pathology with certainty. These 
points will require separate discussion, but it is first necessary to 
describe the character and history of the attack. 

Considerable confusion exists in the description of puerperal con- 
vulsions from the confounding of several essentially distinct diseases 
under the same name. Thus in most obstetric works it has been 
customary to describe three distinct classes of convulsion, the epileptic, 
the hysterical, and the apoplectic. The two latter, however, come 
under a totally different category. A pregnant woman may surfer 
from hysterical paroxysms, or she may be attacked with apoplexy 
accompanied with coma and followed by paralysis. But these con- 
ditions in the pregnant or parturient woman are identical with the 
same diseases in the non-pregnant, and are in no way special in their 
nature. True eclampsia, however, is different in its clinical history 
from epilepsy, although the paroxysms while they last are essentially 
the same as those of an ordinary epileptic fit. 

Premonitory Symptoms. — An attack of eclampsia seldom occurs 
without having been preceded by certain more or less well marked 
precursory symptoms. It is true that in a considerable number of 
cases these are so slight as not to attract attention, and suspicion is not 



586 THE PUERPERAL STATE. 

aroused until the patient is seized with convulsions. Still, subsequent 
investigations will very generally show that some symptoms did exist, 
which, if observed and properly interpreted, might have put the prac- 
titioner on his guard, and possibly have enabled him to ward off the 
attack. Hence a knowledge of them is of real practical value. The 
most common are associated with the cerebrum, such as severe head- 
ache, which is the one most generally observed, and is sometimes 
limited to one side of the head. Transient attacks of dizziness, spots 
before the eyes, loss of sight, or impairment of the intellectual faculties 
are also not uncommon. These signs in a pregnant woman are of the 
gravest import, and should at once call for investigation into the 
nature of the case. Less marked indications sometimes exist in the 
form of irritability, slight headache or stupor, and a geneal feeling of 
indisposition. Another important premonitory sign is oedema of the 
subcutaneous cellular tissue, especially of the face or upper extremities, 
which should at once lead to an examination of the urine. 

Whether such indications have preceded an attack or not, as soon 
as the convulsion comes on there can no longer be any doubt as to the 
nature of the case. The attack is generally sudden in its onset, and 
in its character is precisely that of a severe epileptic fit or of con- 
vulsions in children. Close observation shows that there is at first a 
short period of tonic spasm affecting the entire muscular system. 
This is almost immediately succeeded by violent clonic contractions, 
generally commencing in the muscles of the face, which twitch 
violently; the expression is horribly altered, the globes of the eyes are 
turned up under the eyelids, so as to leave only the white sclerotics 
visible, and the angles of the mouth are retracted and fixed in a con- 
vulsive grin. The tongue is at the same time protruded forcibly, and, 
if care be not taken, is apt to be lacerated by the violent grinding of 
the teeth. The face, at first pale, soon becomes livid and cyanosed, 
while the veins of the neck are distended, and the carotids beat vigor- 
ously. Frothy saliva collects about the mouth, and the whole appear- 
ance is so changed as to render the patient quite unrecognizable. The 
convulsive movements soon attack the muscles of the body. The hands 
and arms, at first rigidly fixed, with the thumbs clenched into the 
palms, begin to jerk, and the whole muscular system is thrown into 
rapidly recurring convulsive spasms. It is evident that the involun- 
tary muscles are implicated in the convulsive action as well as the 
voluntary. This is shown by a temporary arrest of respiration at 
the commencement of the attack, followed by irregular and hurried 
respiratory movements producing a peculiar hissing sound. The 
occasional involuntary expulsion of urine and feces indicates the 
same fact. During the attack the patient is absolutely unconscious, 
sensibility is totally suspended, and she has afterward no recollection 
of what has taken place. Fortunately the convulsion is not of long 
duration, and at the outside does not last more than three or four 
minutes, generally not so long, and it has been pointed out that a 
longer paroxysm would almost necessarily prove fatal on account of 
the implication of the respiratory muscles. In most cases, after an 
interval there is a recurrence of the convulsion characterized by the 



PUERPERAL ECLAMPSIA. 587 

same phenomena, and the paroxysms are repeated with more or less 
force and frequency according to the severity of the attack. Sometimes 
several hours may elapse before a second convulsion comes on ; at 
others the attacks may recur very often, with only a few minutes 
between them. In the slighter forms of eclampsia there may not be 
more than two or three paroxysms in all ; in the more serious as many 
as fifty or sixty have been recorded. 

Condition between the Attacks. — After the first attack the 
patient generally soon recovers her consciousness, being somewhat 
dazed and somnolent, with no clear conception of what has occurred. 
If the paroxysms be frequently repeated, more or less profound coma 
continues in the intervals between them, which no doubt depends 
upon intense cerebral congestion, resulting from interference with the 
circulation in the great veins of the neck, produced by spasmodic con- 
traction of the muscles. The coma is rarely complete, the patient 
showing signs of sensibility when irritated, and groaning during the 
uterine contractions. In the worst class of cases the torpor may 
become intense and continuous, and in this state the patient may die. 
When the convulsions have entirely stopped, and the patient has com- 
pletely regained her consciousness and is apparently convalescent, 
recollection of what has taken place during and some time before the 
attack may be entirely lost, and this condition may last for a con- 
siderable time. A curious instance of this once came under my notice 
in a lady who had lost her brother, to whom she was greatly attached, 
in the week immediately preceding her confinement, and in whom the 
mental distress seemed to have had a great deal to do in determining 
the attack. It was many weeks before she recovered her memory, 
and during that time she recollected nothing about the circumstances 
connected with her brother's death, the whole of that week being, as 
it were, blotted out of her recollection. 

Relation of the Attacks to Labor. — If the convulsions come on 
during pregnancy, we may look upon the advent of labor as almost a 
certainty ; and if we consider the severe nervous shock and general 
disturbance, this is the result we might reasonably anticipate. If they 
occur, as is not uncommon, for the first time during labor, the pains 
generally continue with increased force and frequency, since the uterus 
partakes of the convulsive action. It has not rarely happened that 
the pains have gone on with such intensity that the child has been 
born quite unexpectedly, the attention of the practitioner being taken 
up with the patient. In many cases the advent of fresh paroxysms is 
associated with the commencement of a pain, the irritation of which 
seems sufficient to bring on the convulsion. 

Results to the Mother and Child. — -The results of eclampsia van- 
according to the severity of the paroxysms. It is generally said that 
about one in three or four cases dies. The mortality has certainly 
lessened of late years, probably in consequence of improved knowledge 
of the nature of the disease and more rational modes of treatment. 
This is well shown by Barker, 1 who found in 1885 a mortality of 32 

1 The Puerperal Diseases, p. 125. 



588 THE PUERPEKAL STATE. 

per cent, in cases occurring before and during labor, and 22 per cent. 
in those after labor ; while since that date the mortality has fallen to 
14 per cent. The same conclusion is arrived at by Dr. Phillips, 1 who 
has shown that the mortality has greatly lessened since the practice of 
repeated and indiscriminate bleeding, long considered the sheet-anchor 
in the disease, has been discontinued and the administration of chloro- 
form substituted. 

Cause of Death. — Death may occur during the paroxysm, and then 
it may be due to the long continuance of the tonic spasm producing 
asphyxia. It is certain that, as long as the tonic spasm lasts, the 
respiration is suspended, just as in the convulsive disease of children 
known as laryngismus stridulus ; and it is possible also that the heart 
may share in the convulsive contraction which is known to affect other 
involuntary muscles. More frequently, death happens at a later 
period from the combined effects of exhaustion and asphyxia. The 
records of post-mortem examinations are not numerous ; in those we 
possess, the principal changes have been an auaemic condition of the 
brain, with some cedematous infiltration. In a few rare cases the convul- 
sions have resulted in effusion of blood into the ventricles, or at the base 
of the brain. The prognosis as regards the child is also serious. Out 
of thirty-six children, Hall Davis found twenty-six born alive, ten 
being stillborn. There is good reason to believe that the convulsion 
may attack the child in utero — of this several examples are mentioned 
by Cazeaux; or it may be subsequently attacked with convulsions, even 
when apparently healthy at birth. 

Pathology. — The precise pathology of eclampsia cannot be con- 
sidered by any means satisfactorily settled. When, in the year 1843, 
Lever first showed that the urine in patients suffering from puerperal 
convulsions was generally highly charged with albumin — a fact which 
subsequent experience has amply confirmed — it was thought that a key 
to the etiology of the disease had been found. It was known that 
chronic forms of Bright' s disease were frequently associated with reten- 
tion of urinary elements in the blood, and not rarely accompanied by 
convulsions. The natural inference was drawn that the convulsions of 
eclampsia were also due to toxaemia resulting from the retention of 
urea in the blood, just as in the uraemia of chronic Bright's disease; 
and this view was adopted and supported by the authority of Braun, 
Frerichs, and nianv other writers of eminence, and was pretty generally 
received as a satisfactory explanation of the facts. Frerichs modified 
it so far that he held that the true toxic element was not urea as such, 
but carbonate of ammonia, resulting from its decomposition j and ex- 
periments were made to prove that the injection of this substance into 
the veins of the lower animals produced convulsions of precisely the 
same character as eclampsia. Dr. Hammond, 2 of Maryland, subse- 
quently made a series of counter-experiments which were held as 
proving that there was no reason to believe that urea ever did become 
decomposed in the blood in the way that Frerichs supposed, or that the 

1 Guy's Hospital Reports, 1870. 

2 Amer. Journ. of Med. Sciences, 1861. 



PUERPERAL ECLAMPSIA. 589 

symptoms of uraemia were ever produced in this way. Others have 
believed that the poisonous elements retained in the blood are not urea 
or the products of its decomposition, but other extractive matters 
whicli have escaped detection. As time elapsed, evidence accumulated 
to show that the relation between albuminuria and eclampsia was not 
so universal as was supposed, or at least that some other factors Avere 
necessary to explain many of the cases. Numerous cases were observed 
in which albumin was detected in large quantities, without any con- 
vulsion following, and that not only in women who had been subject 
to Bright's disease before conception, but also when the albumin- 
uria was known to have developed during pregnancy. Thus Imbert 
Goubeyre found that out of 164 cases of the latter kind, 95 had no 
eclampsia ; and Blot, out of 41 cases, found that 34 were delivered 
without untoward symptoms. It may be taken as proved, therefore, 
that albuminuria is by no means necessarily accompanied by eclampsia. 
Cases were also observed in which the albumin only appeared after the 
convulsion ; and in these it was evident that the retention of urinary 
elements could not have been the cause of the attack ; and it is highly 
probable that in them the albuminuria was produced by the same cause 
which induced the convulsion. Special attention has been called to 
this class of cases by Braxton Hicks, 1 who has recorded a considerable 
number of them. He says that the nearly simultaneous appearance of 
albuminuria and convulsion — and it is admitted that the two are almost 
invariably combined — must then be explained in one of three ways : 

1. That the convulsions are the cause of the nephritis. 

2. That the convulsions and the nephritis are produced by the same 
cause, e. g., some detrimental ingredient circulating in the blood, irri- 
tating both the cerebro-spinal system and other organs at the same 
time. 

3. That the highly congested state of the venous system induced by 
the spasm of the glottis in eclampsia is able to produce the kidney 
complication. 

Traube and Rosenstein have advanced a theory of eclampsia purport- 
ing to explain these anomalies. They refer the occurrence of eclampsia 
to acute cerebral anaemia resulting from changes in the blood incident 
to pregnancy. The primary factor is the hydrsetnic condition of the 
blood, which is an ordinary concomitant of pregnancy, and, of course, 
when there is also albuminuria, the watery condition of the blood is 
greatlv intensified ; hence the frequent association of the two states. Ac- 
companying this condition of the blood, there is increased tension of the 
arterial system, which is favored by the hypertrophy of the heart which 
is known to be a normal occurrence in pregnaucy. The result of these 
combined states is a temporary hyperemia of the brain, which is rapidly 
succeeded by serous effusion into the cerebral tissues, resulting in pres- 
sure on its minute vessels and consequent ansemia. There are obvious 
difficulties against the acceptance of this theory. For example, it does 
not satisfactorily account for those cases which are preceded by well-' 

1 Ob>t. Trans., vol. viii. p. 323. 



590 THE PUERPERAL STATE. 

marked precursory symptoms, and in which an abundance of albumin 
is present in the urine. Here the premonitory signs are precisely those 
which precede the development of uraemia in chronic Bright's disease, 
the dependence of which on the retention in the blood of urinary 
elements can hardly be doubted. Moreover, it has been shown by 
Lohlein and others that on post-mortem examination the brain does 
not, as a rule, exhibit the oedema, anaemia, and flattened convolutions 
which this theory assumes. For these reasons this view is now gener- 
allv considered untenable. 

MacDonald 1 has published an interesting paper on this subject, in 
which he describes two very careful post-mortem examinations. In 
these he found extreme anaemia of the cerebro-spinal centres, with con- 
gestion of the meninges, but no evidence of oedema. He inclines to the 
belief that eclampsia is caused by irritation of the vasomotor centre in 
consequence of an anaemic condition of the blood produced by the reten- 
tion in it of excrementitious matters which the kidneys ought to have 
removed, this over-stimulation resulting in anaemia of the deeper-seated 
nerve-centres and consequent convulsion. 

Excitability of the Nervous System in Puerperal Women as 
Predisposing" to Convulsions. — The key to the liability of the puer- 
pera to convulsive attacks is no doubt to be found in the peculiarly 
excitable condition of the nervous system in pregnancy — a fact which 
was clearly pointed out by the late Dr. Tyler Smith and by many other 
writers. Her nervous system is, in this respect, not unlike that of 
children, in whom the predominant influence and great excitability of 
the nervous system are well-established facts, and in whom precisely 
similar convulsive seizures are of common occurrence on the application 
of a sufficiently exciting cause. 

Toxsemic Causes. — Admitting this, we require some cause to set 
the predisposed nervous system into morbid action, and the tendency 
of modern opinion is to refer this to a toxaeniic condition of the blood. 
The precise character and origin of the toxins are not known, but is it 
probable that they are the results of tissue changes, both in the mother 
and foetus, and that they act detrimentally when their elimination is 
interfered with by some morbid condition of the kidneys, or liver, or 
both, which leads to their retention in the blood. The frequency of 
kidney changes in connection with pregnancy has been insisted on by 
Leyden, of Berlin, and they are frequently found in fatal cases of 
eclampsia; Zweifel 2 states that multiple thromboses always exist in the 
vessels of the liver, lungs, and brain, showing the action of some as yet 
undetermined toxin in producing blood coagulation. It has even been 
supposed that a special bacillus, of which cultures have been made, exists 
in eclampsia, which produces the toxic material causing convulsions. 
The accuracy of this statement has, however, been denied by subsequent 
observers. 

Treatment. — The management of cases in which the occurrence of 

1 See his volume of collected essays, entitled Heart Disease during Pregnancy. London, 1878. 

2 Centralblatt. f. Gynak.. 1895. 



PUERPERAL ECLAMPSIA. 591 

suspicious symptoms has led to the detection of albuminuria has already 
been fully discussed. We shall therefore, here, only consider the treat- 
ment of cases in which convulsions have actually occurred. 

Formerly venesection was regarded as the sheet-anchor in the treat- 
ment, and blood was always removed copiously, and, there is sufficient 
reason to believe, with occasional remarkable benefit. Many cases are 
recorded in which a patient, in apparently profound coma, rapidly 
regained her consciousness when blood was extracted in sufficient quan- 
tity. The improvement, however, was ofteu transient, the convulsions 
subsequently recurring with increased vigor. There are good theoretical 
grounds for believing that bloodletting cau only be of merely temporary 
use, and may even increase the tendency to convulsion. These are so 
well put by Schroeder that I cannot do better than quote his observa- 
tions on this point. " From experience it is known that after venesec- 
tion the quantity of blood soon becomes the same through the serum 
taken from all the tissues, while the quality is greatly deteriorated by 
the abstraction of blood. A short time after venesection we shall 
expect to find the former blood-pressure in the arterial system, but the 
blood far more watery than previously. From this theoretical consid- 
eration, it follows that abstraction of blood, if the above-mentioned 
conditions really cause convulsions, must be attended by an immediate 
favorable result, and, under certain circumstances, the whole disease 
may surely be cut short by it. But, if all other conditions remain the 
same, the blood-pressure will after some time again reach its former 
height. The quality of blood has in the meantime been greatly deteri- 
orated, and consequently the clanger of the disease will be increased." 

These views sufficiently well explain the varying opinions held with 
regard to this remedy, and enable us to understand why, while the 
effects of venesection have been so lauded by certain authors, the mor- 
tality has admittedly been much lessened since its indiscriminate use 
has been abandoned. It does not follow because a remedy, when 
carried to excess, is apt to be hurtful that it should be discarded 
altogether ; and I have no doubt that in properly selected cases and 
judiciously employed, venesection is a valuable aid in the treatment of 
eclampsia, and that it is specially likely to be useful in mitigating the 
first violence of the attack and in giving time for other remedies to 
come into action. Care should, however, be taken to select the cases 
properly, and it will be specially indicated when there is marked 
evidence of great cerebral congestion and vascular tension, such as a 
livid face, a full bounding pulse, and strong pulsation in the carotids. 
The general constitution of the patient may also serve as a guide in 
determining its use, and we shall be the more disposed to resort to it 
if the patient be a strong and healthy woman j while on the other 
hand, if she be feeble and weak, we may wisely discard it and trust 
entirely to other means. In any case it must be looked upon as a 
temporary expedient only, useful in warding off immediate danger to 
the cerebral tissues, but never as the main agent in treatment. Nor 
can it be permissible to bleed in the heroic manner frequently recom- 
mended. A single bleeding, the amount regulated by the effect 
produced, is all that is ever likely to be of service. 



592 THE PUERPERAL STATE. 

As a temporary expedient, having the same object in view, com- 
pression of the carotids during the paroxysms is worthy of trial. This 
Avas proposed by Trousseau in the eclampsia of infants, and in the 
single case of eclampsia in which I have tried it, it seemed decidedly 
beneficial. It is simple, and it offers the advantage of not leading 
to any permanent deterioration of the blood, as in venesection. 

As a subsidiary means of diminishing vascular tension the admin- 
istration of a strong purgative is desirable, and has the further effect 
of removing any irritant matter that may be lodged in the intestinal 
tract. As it is probable that the liver is concerned in the production 
of toxins in eclampsia, free purgation is likely to be useful in lessening 
their formation or promoting their elimination. If the patient be con- 
scious, a full dose of the compound jalap powder may be given, or a 
few grains of calomel combined with jalap ; and if she be comatose and 
unable to swallow, a drop of croton oil or a quarter of a grain of elate- 
rium may be placed on the back of the tongue. 

The great indication in the management of eclampsia is the con- 
trolling of convulsive action by means of sedatives. Foremost amongst 
them must be placed the inhalation of chloroform, a remedy which is 
frequently remarkably useful, and which has the advantage of being 
applicable at all stages of the disease, and whether the patient be 
comatose or not. Theoretical objections have been raised against its 
employment, as being likely to increase cerebral congestion : of this 
there is no satisfactory proof; on the contrary there is reason to think 
that chloroform inhalation has rather the effect of lessening arterial 
tension, while it certainly controls the violent muscular action by 
which the hyperemia is so much increased. Practically no one who 
has used it can doubt its great value in diminishing the force and 
frequency of the convulsive paroxysms. Statistically its usefulness is 
shown by Charpentier in his thesis on the effects of various methods 
of treatment in eclampsia, since out of sixty-three cases in which it 
was used, in forty-eight it had the effect of diminishing or arresting 
the attacks, one only proving fatal. The mode of administration has 
varied. Some have given it almost continuously, keeping the patient 
in a more or less profound state of anaesthesia. Others have contented 
themselves with carefully watching the patient, and exhibiting the 
chloroform as soon as there were any indications of a recurring 
paroxysm, with the view of controlling its intensity. The latter is 
the plan I have myself adopted, and of the value of which in most 
cases I have no doubt. Every now and again cases will occur in 
which chloroform inhalation is insufficient to control the paroxysm, or 
in which, from the very cyanosed state of the patient, its administra- 
tion seems contra-indicated. Moreover, it is advisable to have, if 
possible, some remedy more continuous in its action and requiring 
less constant personal supervision. Latterly the internal administra- 
tion of chloral has been recommended for this purpose. My own 
experience is decidedly in its favor, and I have used, with, as I believe, 
marked advantage, a combination of chloral with bromide of potassium, 
in the proportion of twenty grains of the former to half a drachm of 



PUERPERAL ECLAMPSIA. 593 

the latter, repeated at intervals of from four to six hours. If the 

patient be unable to swallow, the chloral may be given in an enema 

or kypodermieally, six grains being diluted in 5j of water, and injected 

under the skin. The remarkable influence of bromide of potassium 

in controlling the eclampsia of infants would seem to be an indication 

for its use in puerperal cases. Fordvce Barker was opposed to the use 

of chloral, which he thought excited instead of lessening reflex irrita- 

. . ... 

bility. Another remedy, not entirely free from theoretical objections, 

but strongly recommended, is the subcutaneous injection of morphia, 
which has the advantage of being applicable when the patient is quite 
unable to swallow. It may be given in doses of one-third of a grain, 
repeated in a few hours, so as to keep the patient well under its influ- 
ence. It is to be remembered that the object is to control muscular 
action, so as to prevent as much as possible the violent convulsive 
paroxysm, and, therefore, it is necessary that the narcosis, however pro- 
duced, should be continuous. It is rational, therefore, to combine the 
intermittent action of chloroform with the more continuous action of 
other remedies, so that the former should supplement the latter when 
insufficient. Inhalation of the nitrite of amyl has been recommended 
on physiological grounds as likely to be useful, and is well worthy of 
trial ; but of its action I have, as yet, no personal experience. Several 
very successful cases of treatment by the inhalation of oxygen have 
been recorded by Schmidt, of St. Petersburg. 2 Pilocarpine has recently 
been tried, in the hope that the diaphoresis and salivation it produces 
might diminish arterial tension and free the blood of toxic matters. 
Braun 3 administered three centigrammes of the muriate of pilocarpine 
hypodermically, and reports favorably of the result ; Fordvce Barker, 4 
however, was of opinion that it produced so much depression as to be 
dangerous. 

Other remedies, supposed to act in tiie way of antidotes to ursemic 
poisoning, have been advised, such as acetic or benzoic acid, but they 
are far too uncertain to have any reliance placed on them, and they 
distract attention from more useful measures. 

Precautions during- the Paroxysm. — Precautions are necessary 
during the fits to prevent the patient injuring herself, especially to 
obviate laceration of the tongue ; the latter can be best done by placing 
something between the teeth as the paroxysm comes on, such as the 
handle of a teaspoon enveloped in several folds of flannel. 

Obstetric Management — The obstetric management of eclampsia 
will naturally give rise to much anxiety, and on this point there has 
been considerable difference of opinion. On the one hand we have 
practitioners who advise the immediate emptying of the uterus, even 
when labor has not commenced; on the other, those who would leave 
the labor entirely alone. Thus Gooch said : "Attend to the convulsions, 
and leave the labor to take care of itself;" and Schroeder said : " Espe- 
cially no kind of obstetric manipulation is required for the safety of 
the mother," but he admitted that it is sometimes advisable to hasten 
the labor to insure the safety of the child. 

1 The Puerperal Diseases, p. 120. 

2 London Med. Record, vol. xiv. p. 75. (Extr. from Russkaia Meditz, No. 32, p. 595.) 

3 Berl. klin. Wocheuschr.. June 16, 1879. 4 New York Med. Record, March 1, 1879. 

38 



594 THE PUERPERAL STATE. 

In cases in which the convulsions come on during labor, the pains 
are often strong and regular, the labor progresses satisfactorily, and 
no interference is needful. In others we cannot but feel that empty- 
ing the uterus would be decidedly beneficial. We have to reflect, 
however, that any active interference might, of itself, prove very 
irritating and excite fresh attacks. The influence of uterine irritation 
is apparent by the frequency with which the paroxysms recur with 
the pains. If, therefore, the os be undilated and labor have not 
begun, no active means to induce it should be adopted, although the 
membranes may be ruptured with advantage, since that procedure 
produces no irritation. Forcible dilatation of the os, and especially 
turning, are strongly contra-indicated. 

The rule laid down by Tyler Smith seems that which is most 
advisable to follow — that we should adopt the course which seems 
least likely to prove a source of irritation to the mother. Thus, if 
the fits seem evidently induced and kept up by the pressure of the 
foetus, and the head be within reach, the forceps may be resorted to. 
But if, on the other hand, there be reason to think that the operation 
necessary to complete delivery is likely per se to prove a greater 
source of irritation than leaving the case to Nature, then we should 
not interfere. 



CHAPTER IV. 

PUERPERAL INSANITY. 

Classification. — Under the head of " Puerperal Mania," writers- 
ou obstetrics have indiscriminately classed all cases of mental disease 
connected with pregnancy and parturition. The result has been unfor- 
tunate, for the distinction between the various types of mental disorder 
has, in consequence, been very generally lost sight of. But little study 
of the subject suffices to show that the term puerperal mania is wrong 
in more ways than one, for we find that a large number of cases are 
not cases of " mania " at all, but of melancholia ; while a considerable 
number are not, strictly speaking, " puerperal," as they either come 
on during pregnancy, or long after the immediate risks of the puerperal 
period are over, being in the latter case associated with ansemia pro- 
duced by over-lactation. For the sake of brevity the generic term, 
" puerperal insanity," may be employed to cover all cases of mental 
disorders connected with gestation, which may be further conveniently 
subdivided into three classes, each having its special characteristics,, 
viz. : 



PUERPERAL INSANITY. 595 

I. The insanity of pregnancy. 
II. Puerperal insanity, properly so called ; that is, insanity coming 
on within a limited period after delivery. 
III. The insanity of lactation. 

This division is a strictly natural one, and includes all the cases 
likely to come under observation.. The relative proportion these 
classes bear to each other can only be determined by accurate statistical 
observations on a large scale, but these materials Ave do not possess. 
The returns from large asylums are obviously open to objection, for 
only the worst and most confirmed cases find their way into these 
institutions, while by far the greater proportion, both before and after 
labor, are treated in their own homes. 

Proportion of these forms of insanity. Taking such returns 
as only approximate, we find from Dr. Batty Tuke 1 that in the Edin- 
burgh Asylum, out of 155 cases of puerperal insanity, 28 occurred 
before delivery, 73 during the puerperal period, and 54 during lacta- 
tion. The relative proportions of each per hundred are as follows : 

Insanity of pregnancy 18.06 per cent. 

Puerperal insauity 47.09 " 

Insanity of lactation 34.83 " 

Marce 2 collects together several series of cases from various authorities, 
amounting to 310 in all, and the results are not very different from 
those of the Edinburgh Asylum, except in the relatively smaller 
number of cases occurring before delivery. The percentage is calcu- 
lated from his figures : 

Insanity of pregnancy 8.06 per cent. 

Puerperal insanity 58.06 " 

Insanity of lactation ... 30.30 " 

As each of these classes differs in various important respects from the 
others, it will be better to consider each separately. 

The Insanity of Pregnancy is, without doubt, the least common 
of the three forms. The intense mental depression which in many 
women accompanies pregnancy, and causes the patient to take a 
despondent view of her condition, and to look forward to the result 
of her labor with the most gloomy apprehension, seems to be often 
only a lesser degree of the actual mental derangement which is occa- 
sionally met with. The relation between the two states is further 
borne out by the fact that a large majority of cases of insanity during 
pregnancy are well-marked types of melancholia ; out of 28 cases 
recorded by Tuke, 15 were examples of pure melancholia, and 5 of 
dementia with melancholia. In many of these the attack could be 
traced as developing itself out of the ordinary hypochondriasis of 
pregnancy. In others the symptoms came on at a later period of 
pregnancy, the earlier months of which had not been marked by any 
unusual lowness of spirits. The age of the patient seems to have 
some influence, the proportion of cases between thirty and forty years 

1 Edin. Med. Journ., vol. x. a Traite de la Folie des Femmes enceintes. 



696 THE PUERPERAL STATE. 

of age being much larger than in younger women. A larger propor- 
tion of cases occurs in primipara than in multipara, a fact that no 
doubt depends on the greater dread and apprehension experienced by 
women who are pregnant for the first time, especially if not very 
young. Hereditary disposition plays an important part, as in all 
forms of puerperal insanity. It is not always easy to ascertain the 
fact of an hereditary taint, since it is often studiously concealed by 
the friends. Tuke, however, found distinct evidence of it in no less 
than 12 out of 28 cases. Fiirstner 1 believes that other neuroses have 
an important influence in the production of the disease. Out of 32 
cases he found direct hereditary taint in 9, but in 1 1 more there was 
a family history of epilepsy, drunkenness, or hysteria. 

Period of pregnancy at which it occurs. The period of preg- 
nancy at which mental derangement most commonly shows itself 
varies. Most generally, perhaps, it is at the end of the third or the 
beginning of the fourth month. It may, however, begin with con- 
ception, and even return with every impregnation. Montgomery 
relates an instance in which it recurred in three successive pregnan- 
cies. Marce distinguishes between true insanity coming on during 
pregnancy and aggravated hypochondriasis, by the fact that the latter 
usually lessens after the third month, while the former most com- 
monly begins after that date. It is unquestionable that in many cases 
no such distinction can be made, and that the two are often very inti- 
mately associated. 

The form of insanity does not differ from ordinary melancholia. 
The suicidal tendency is generally very strongly developed. Should 
the mental disorder continue after delivery, the patient may very 
probably experience a strong impulse to kill her child. Moral per- 
versions have not been uncommonly observed. Tuke especially men- 
tions a tendency to dipsomania in the early months, even in women 
who have not shown any disposition to excess at other times. He 
suggests that this may be an exaggeration of the depraved appetite or 
morbid craving so commonly observed in pregnant women, just as 
melancholia may be a further development of lowness of spirits. 
Laycock mentions a disposition to " kleptomania" as very character- 
istic of the disease. Casper 2 relates a curious case where this occurred 
In a pregnant lady of rank, and the influence of pregnancy in devel- 
oping an irresistible tendency was pleaded in a criminal trial in which 
one of her petty thefts had involved her. 

The prognosis may be said to be, on the whole, favorable. Out of 
Dr. Tuke's twenty-eight cases, nineteen recovered within six months. 
There is little hope of a cure until after the termination of the preg- 
nancy, as out of nineteen cases recorded by Marce, in only two did 
the insanity disappear before delivery. 

Transient Mania during" Delivery. — There is a peculiar form of 
mental derangement sometimes observed during labor, which is by 
some talked of as a temporary insanity. It may, perhaps, be more 

1 Archiv fur Psychiatrie, Band v. Heft 2. 

8 Casper's Forensic Medicine, New Syd. Soc, vol. iv. p. 30S. 



PUERPERAL INSANITY. 597 

accurately described as a kind of acute delirium, produced, in the 
latter stage of labor, by the intensity of the suffering caused by the 
pains. According to Montgomery, it is most apt to occur as the head 
is passing through the os uteri, or at a later period, during the expul- 
sion of the child. It may consist of merely a loss of control over the 
mind, during which the patient, unless carefully watched, might, in her 
agony, seriously injure herself or her child. Sometimes it produces 
actual hallucination, as in the case described by Tarnier, in which the 
patient fancied she saw a spectre standing at the foot of her bed, 
which she made violent effort to drive away. This kind of mania, if 
it may be so called, is merely transitory in its character, and disap- 
pears as soon as the labor is over. From a medico-legal point of view 
it may be of importance, as it has been held by some that in certain 
cases of infanticide the mother has destroyed the child when in this 
state of transient frenzy, and when she was irresponsible for her acts. 
In the treatment of this variety of delirium we must, of course, try 
to lessen the intensity of the suffering, and it is in such cases that 
chloroform will find one of its most valuable applications. 

True Puerperal Insanity has always attracted much attention from 
obstetricians, often to the exclusion of other forms of mental disturb- 
ance connected with the puerperal state. "We may define it to be that 
form of insanity which comes on within a limited period after delivery, 
and which is probably intimately connected with that process. Out 
of seventy-three examples of the disease tabulated by Dr. Tuke, only 
two came on later than a month after delivery, and in these there were 
other causes present, which might possibly remove them from this 
class. 

Although a large number of these cases assume the character of 
acute mania, that is by no means the only kind of insanity which is 
observed, a not inconsiderable number being well-marked examples of 
melancholia. The distinction between them was long ago pointed out 
by Gooch, whose admirable monograph on the disease contains one ot 
the most graphic and accurate accounts of puerperal insanity that has 
yet been written. 

There are also some peculiarities as to the period at which these 
varieties of insanity show themselves, which, taken in connection with 
certain facts in their etiology, may eventually justify us in drawing a 
stronger line of demarcation between them than has been usual. It 
appears that cases of acute mania are apt to come on at a period much 
nearer delivery than melancholia. Thus Tuke found that all the 
cases of mania came on within sixteen days after delivery, and that all 
cases of melanchola developed themselves after that period. We 
shall presently see that one of the most recent theories as to the cause 
of the disease attributes it to some morbid condition of the blood. 
Should further investigation confirm this supposition, inasmuch as 
septic conditions of the blood are most likely to occur a short time 
after labor, it would not be an improbable hypothesis that cases of 
acute mania, occurring within a short time after labor, may depend on 
such septic causes, while melancholia is more likely to arise from 



598 THE PUERPERAL STATE. 

general conditions favoring the development of mental disease. This 
must, however, be regarded as a mere speculation, requiring further 
investigation. 

Causes. — Hereditary predisposition is very frequently met with, 
and a careful inquiry into the patient's history will generally show 
that other members of the family have suffered from mental derange- 
ment. Even where there is no evidence of actual insanity in the 
patient's family, it may be possible to trace hereditary tendency to 
extreme nervous temperament and neurotic illness more or less allied 
to it. Reid found that out of 111 cases in Bethlehem Hospital, there 
was clear evidence of hereditary taint in 45. Tuke made the same 
observation in 22 out of his 73 cases; and, indeed, it is pretty gen- 
erally admitted by all alienist physicians that hereditary tendencies 
form one of the strongest predisposing causes of mental disturbance 
in the puerperal state. In a large proportion of cases circumstances 
producing debility and exhaustion, or mental depression, have pre- 
ceded the attack. Thus it is often found that patients attacked with 
it have had post-partum hemorrhage or have suffered from some other 
conditions producing exhaustion, such as severe and complicated labor; 
or they may have been weakened by over-frequent pregnancies, or by 
lactation during the early months of pregnancy. Indeed, anaemia is 
always well marked in this disease. Mental conditions also are fre- 
quently traceable in connection with its production. Morbid dread 
during pregnancy, insufficient to produce insanity before delivery, 
may develop into mental derangement after it. Shame and fear of 
exposure in unmarried women not unfrequently lead to it, as is evi- 
denced by the fact that out of 2281 cases gathered from the reports 
of various asylums, above 64 per cent, were unmarried. Sudden 
moral shocks or vivid mental impressions may be the determining 
cause in predisposed persons. Gooch narrated an example of this in 
a lady who was attacked immediately after a fright produced by a tire 
close to her. house, the hallucinations in this case being all connected 
with light; and Tyler Smith that of another whose illness dated from 
the sudden death of a relative. The age of the patient has some 
influence, and there seems to be a decidedly greater liability at 
advanced ages, especially when such women are pregnant for the first 
time. 

The possibility of the acute form of puerperal insanity coming on 
shortly after delivery being dependent on some form of septicaemia, is 
one which deserves careful consideration. The idea originated with 
Sir James Simpson, who found albumin in the urine of four patients. 
He suggested that this might probably indicate the presence in the 
blood of certain urinary constituents which might have determined 
the attack much in the same way as in eclampsia. Dr. Donkin sub- 
sequently wrote an important paper, 1 in which he warmly supported 
this theory, and arrived at the conclusion " that the acute dangerous 
class of cases are examples of ursemie blood-poisoning, of which the 
mania, rapid pulse, and other constitutional symptoms are merely the 

i Edin. Med. Journ., vol. vii. 



PUERPERAL INSANITY. 599 

phenomena ;" and that the affection, therefore, ought to be termed 
uremic or renal puerperal mania, in contradistinction to the other 
form of disease. It will be observed, therefore, that the pathological 
condition producing puerperal mania would, supposing this theory to 
be correct, be precisely the same as that which at other times is sup- 
posed to give rise to puerperal eclampsia. As a matter of fact, meutal 
complications have been noted as following eclampsia in a considerable 
proportion of cases, said to vary from 5 to 6 per cent. There can be 
no doubt that the patient, immediately after delivery, is in a condition 
rendering her peculiarly liable to various forms of septic disease; and 
it must be admitted that there is no inherent improbability in the sup- 
position that some morbid material circulating in the blood may be the 
effective cause of the attack in a person otherwise predisposed to it. It 
is also certain, as I have already pointed out, that there are two distinct 
classes of cases, differing according to the period after delivery at which 
the attack comes on. Whether this difference depends on the presence 
in the blood of some toxic matter is a question which our knowledge 
by no means justifies us in answering ; it is, however, one which well 
merits further careful study. 

It is only fair to point out some difficulties which appear to militate 
against the view which Dr. Donkin maintains. In the first place, the 
albuminuria is merely transient, while its supposed effects last for 
weeks or months. Sir James Simpson said, with regard to his cases: 
" I have seen all traces of albuminuria in puerperal insanity disappear 
from the urine within fifty hours of the access of the malady. The 
general rapidity of its disappearance is, perhaps, the principal or, 
indeed, the only reason why this complication has escaped the notice of 
those physicians among us who devote themselves with such ardor and 
zeal to the treatment of insanity in our public asylums." This apparent 
anomaly Simpson attempted to explain by the hypothesis that, when 
once the ursernic poisoning has done its work and set the disease in pro- 
gress, the mania progresses of itself. This, however, is pure specula- 
tion; and, in the supposed analogous case of eclampsia, the albuminuria 
certainly lasts as long as its effects. It is not easy to understand, also, 
why toxaemia should in one case give rise to insanity and in another to 
convulsions. For all we know to the .contrary, transient albuminuria 
may be much more common after delivery than has been generally sup- 
posed, and futher investigation on this point is required. Albumin is 
by no means unfrequently observed in the urine for a short time in 
various conditions of the body, without any serious consequences, as, 
for example, after bathing ; and we may too readily draw an unjustifi- 
able conclusion from its detection in a few cases of mania. 

The prognosis of puerperal insanity is a point which will always 
deeplv interest those who have to deal with so distressing a malady. 
It mav resolve itself into a consideration of the immediate risk to life 
and of the chances of ultimate restoration of the mental faculties. It 
is an old aphorism of Gooch's, and one the correctness of which is jus- 
tified by modern experience, that " mania is more dangerous to life, 
melancholia to reason." It has very generally been supposed that the 
immediate risk to life in puerperal mania is not great, and on the whole 



600 THE PUERPERAL STATE. 

this niay be taken as correct. Tuke found that death took place, from 
all causes, in 10.9 per cent, of the cases under observation; these, how- 
ever, were all women who had been admitted into asylums and in 
whom the attack may be assumed to have been exceptionally severe. 
Great stress was laid by Hunter and Gooch on extreme rapidity of the 
pulse as indicating a fatal tendency. There can be no doubt that it is 
a symptom of great gravity, but by no means one which need lead us 
to despair of our patient's recovery. The most dangerous class of cases 
are those attended with some inflammatory complication ; and if there 
be marked elevation of temperature, indicating the presence of some 
such concomitant state, our prognosis must be more grave than when 
there is mere excitement of the circulation. 

Post-mortem signs. There are no marked post-mortem signs 
found in fatal cases to guide us in forming an opinion as to the nature 
of the disease. " No constant morbid changes," says Tyler Smith, " are 
found within the head, and most frequently the only condition found 
in the brain is that of unusual paleness and exsanguinity. Many 
pathologists have also remarked upon the extremely empty condition 
of the bloodvessels, particularly the veins. 

The duration of the disease varies considerably. Generally speak- 
ing, cases of mania do not last so long as melancholia, and recovery 
takes place within a period of three months, often earlier. Very few 
of the cases admitted into the Edinburgh Asylum remained there more 
than six months, and after that time the chances of ultimate recovery 
greatly lessened. When the patient gets well it often happens that her 
recollection of the events occurring during her illness is lost ; at other 
times the delusions from which she suffered remain, as, for example, 
in a case which was under my care, in which the personal antipathies 
which the patient formed when insane became permanently established. 

Insanity of Lactation. — Fifty-four out of the 155 cases collected 
by Dr. Tuke were examples of the insanity of lactation, which would 
appear, therefore, to be nearly twice as common as that of pregnancy, 
but considerably less so than the true puerperal form. Its dependence 
on causes producing anaemia and exhaustion is obvious and well 
marked. In the large majority of cases it occurs in multipara who 
have been debilitated by frequent pregnancies and by length of nurs- 
ing. When occurring in primiparse it is generally in women who 
have suffered from post-partum hemorrhage or other causes of exhaus- 
tion, or whose constitution was such as should have contra-indicated 
any attempt at lactation. The " bruit de diable" is almost invariably 
present in the veins of the neck, indicating the impoverished condition 
of the blood. 

The type is far more frequently melancholic than maniacal, and 
when the latter form occurs, the attack is much more transient than in 
true puerperal insanity. The danger to life is not great, especially if 
the cause producing debility be recgnized and at once removed. 

There seems, however, to be more risk of the insanity becoming 
permanent than in the other forms. In twelve out of Dr. Tuke's cases 
the melancholia degenerated into dementia and the patients became 
hopelessly insane. 



PUERPERAL INSANITY. 601 

Symptoms. — The symptoms of these various forms of insanity are 
practically the same as in the non-pregnant state. 

Generally in cases of mania there is more or less premonitory indi- 
cation of mental disturbance, which may pass unperceived. The attack 
is often preceded by restlessness and loss of sleep, the latter being a 
very common and well-marked symptom ; or if the patient does sleep, 
her rest is broken and disturbed by dreams. Causeless dislikes to 
those around her are often observed ; the nurse, the husband, the 
doctor, or the child, becomes the object of suspicion, and unless proper 
care be taken the child may be seriously injured. As the disease 
advances the patient becomes incoherent and rambling in her talk, 
and, in a fully developed case, she is incessantly pouring forth an un- 
connected jumble of sentences, out of which no meaning can be made. 
Often some prevalent idea which is dwelling in the patient's mind can 
be traced running through her ravings, and it has been noticed that 
this is frequently of a sexual character, causing women of unblemished 
reputation to use obscene and disgusting language, which it is difficult 
to understand their even having heard. The tendency of such patients 
to make accusations impugning their own chastity was specially insisted 
on by many eminent authorities in a recent celebrated trial, when Sir 
James Simpson stated that in his experience " the organ diseased gave 
a type to the insanity, so that with women suffering with affections of 
the genital organs the delusions would be more likely to be connected 
with sexual matters." Religious delusions — as a fear of eternal damna- 
tion, or of having committed some unpardonable sin — are of frequent 
occurrence, but perhaps more often in cases which are tending to the 
melancholic type. There is generally intolerable restlessness, and the 
patient's Avhole manner and appearance are those of excessive excite- 
ment. She may refuse to remain in bed, may tear off her clothes, or 
attempt to injure herself. The suicidal tendency is often very marked. 
In one case under my care the patient made incessant efforts to destroy 
herself, which were only frustrated by the most careful watching ; she 
endeavored to strangle herself with the bedclothes, to swallow any 
article she could lay hold of, and even to gouge out her own eyes. 
Food is generally persistently refused, and the utmost coaxing may 
fail in inducing the patient to take nourishment. The pulse is rapid 
and small, and the more violent the excitement and furious the 
delirium, the more excited is the circulation. The tongue is coated 
and furred, the bowels constipated and disorded, and the feces, as well 
as the urine, are frequently passed involuntarily. The urine is scanty 
and high-colored, and after the disease has lasted for some time it 
becomes loaded with phosphates. The lochia and the secretion of milk 
generallv become arrested at the commencement of the disease. The 
waste of tissue, from the incessant restlessness and movement of the 
patient, is very great ; and if the disease continues for some time she 
falls into a condition of marasmus, which nnfy be so excessive that 
she becomes wasted to a shadow of her former size. 

When the insanity assumes the form of melancholia, its advent is 
more Gradual. It may commence with depression of spirits, without 



602 THE PUERPERAL STATE. 

any adequate cause, associated with insomnia, disturbed digestion, head- 
ache, and other indications of bodily derangement. Such symptoms 
showing themselves in women who have been nursing for a length of 
time, or in whom any other evident cause of exhaustion exists, should 
never pass unnoticed. Soon the signs of mental depression increase 
and positive delusions show themselves. These may vary much in 
their amount, but they are all more or less of the same type, and very 
often of a religious character. The amount of constitutional disturb- 
ance varies much. In some cases which approach in character those 
of mania, there is considerable excitement, rapid pulse, furred tongue, 
and restlessness. Probably cases of acute melancholia, coming on 
during the puerperal state, most often assume this form. In others, 
again, there is less of these general symptoms, the patients are pro- 
foundly dejected, and sit for hours without speaking or moving, but 
there is not much excitement, and this is the form most generally 
characterizing the insanity of lactation. In all cases there is a marked 
disinclination to food. There is also, almost invariably, a disposition 
to suicide ; and it should never be forgotten in melancholic cases that 
this may develop itself in an instant, and that a moment's carelessness 
on the part of the attendants may lead to disastrous results. 

Treatment. — Bearing in mind what has been said of the essential 
character of puerperal insanity, it is obvious that the course of treat- 
ment must be mainly directed to maintain the strength of the patient, 
so as to enable her to pass through the disease without fatal exhaustion 
of the vital powers, while we endeavor at the same time to calm the 
excitement and give rest to the disturbed brain. Any over-active 
measures — for example, bleeding, blistering the shaven scalp, and the 
like — are distinctly contra-indicated. 

There is a general agreement on the part of alienist physicians that 
in cases of acute mania the two things most needed are a sufficient 
quantity of suitable food and sleep. 

Every endeavor should be made to induce the patient to take plenty 
of nourishment to remedy the defects of the excessive waste of tissue 
and support her strength until the disease abates. Dr. Blandford, who 
has especially insisted on the importance of this, says : * " Now wdth 
regard to the food, skilful attendants will coax a patient into taking a 
large quantity, and we can hardly give too much. Messes of minced 
meat with potato and greens, diluted with beef-tea, bread and milk, 
rum and milk, arrowroot, and so on, may be got down. Never give 
mere liquids as long as you can get down solids. As the malady 
progresses, the tongue and mouth may become so dry and foul that 
nothing but liquids can be swallowed ; but, reserving our beef-tea and 
brandy, let us give plenty of solid food while we can." 

The patient may in mania, as well as in melancholia, perhaps even 
more in the latter, obstinately refuse to take nourishment at all, and 
we may be compelled "to use force. Various contrivances have been 
employed for this purpose. One of the simplest is introducing a 

i Blandford : Insanity and its Treatment. 



PUERPERAL INSANITY. 603 

dessertspoon forcibly between the teeth, the patient being controlled 
by an adequate number of attendants, and slowly injecting into the 
mouth suitable nourishment by an India-rubber bottle with an ivory 
nozzle, such as is sold by all chemists. Care must be taken not to 
inject more than an ounce at a time, and to allow the patient to breathe 
between each deglutition. So extreme a measure will seldom be 
required if the patient have experienced attendants who can overcome 
her resistance to food by gentler means ; but it may be essential, and 
it is far better to employ it than to allow the patient to become ex- 
hausted from want of nourishment. In one case I had to feed a patient 
in this May three times a day for several weeks, and used lor the 
purpose a contrivance known in asylums as Paley's feeding-bottle, 
which reduced the difficulty of the process to a minimum. Beef-tea 
or strong soup, mixed with some farinaceous material, such as Reva- 
lenta Arabica or wheaten flour, or milk, forms the best mess for this 
purpose. 

In the early stages the patient is probably better without stimulants, 
which seem only to increase the excitement. As the disease progresses 
and exhaustion becomes marked, it may be necessary to have recourse 
to them. In melancholia they seem to be more useful, and may be 
administered with greater freedom. 

The state of the bowels requires especial attention. They are almost 
always disordered, the evacuations being dark and offensive in odor. 
In the early stages of the disease the prompt clearing of the bowels by 
a suitable purgative sometimes has the effect of cutting short an im- 
pending attack. A curious example of this is recorded by Gooch, in 
which the patient's recovery seemed to date from the free evacuation 
of the bowels. A few grains of calomel, or a dose of compound jalap 
powder, or of castor oil, may generally be readily given. During the 
continuance of the illness the state of the primae vise should be attended 
to, and occasional aperients will be useful, but strong and repeated 
purgation is hurtful from the debility it produces. 

One of the most important points of treatment is to procure sleep. 
For this purpose there is no drug so valuable as the hydrate of choral, 
either alone or in combination with bromide of potassium, which has 
a distinct effect in increasing its hypnotic action. Given in a full dose 
at bedtime, say from fifteen grains to half a drachm, it rarely fails in 
procuring at least some sleep, and in an early stage of acute mania 
this may be followed by the best effects. It may be necessary to 
repeat this draught night after night, during the acute stage of the 
malady. If we cannot induce the patient to swallow the medicine it 
may be given in the form of enema. Chloral, however, caunot be 
administered for any length of time without detriment to the patient, 
and it is advisable to alternate it with other hypnotics, such as sul- 
phonal, chloralamide, or paraldehyde. 

It is generally admitted that in mania, preparations of opium, for- 
med v much relied on in the treatment of the disease, are apt to do 
more harm than good. Dr. Blandf'ord gives a strong opinion on this 
point. He says : %i In prolonged delirious mania I believe opium 



604 THE PUERPERAL STATE. 

never does good, and may do great harm. We shall see the effects of 
narcotic poisoning if it be pushed, but none that are beneficial. This 
applies equally to opium given by the mouth and by subcutaneous 
injection. The latter, as it is more certain and effectual in producing 
good results, is also more deadly when it acts as a narcotic poison. 
After the administration of a dose of morphia by the subcutaneous 
method, the patient will probably at once fall asleep, and we con- 
gratulate ourselves that our long-wished -for object is attained. But 
after half an hour or so the sleep suddenly terminates, and the mania 
and excitement are worse than before. Here you may possibly think 
that, had the dose been larger, instead of half an hour's sleep you 
would have obtained one of longer duration, and you may administer 
more, but with a like result. Large doses of morphia not merely fail 
to produce refreshing sleep ; they poison the patient, and produce, if 
not the symptoms of actual narcotic poisoning, at any rate that typhoid 
condition which indicates prostration and approaching collapse. I 
believe there is no drug the use of which more often becomes abused 
than that of opium." It is otherwise in cases of melancholia, espe- 
cially in the more chronic forms. In these, opiates in moderate doses, 
not pushed to excess, may be given with great advantage. The sub- 
cutaneous injection of morphia is by far the best means of exhibiting 
the drug, from its rapidity of action and facility of administration. 

There are other methods of calming the excitement of the patient 
besides the use of medicines. The prolonged use of the warm bath, 
the patient being immersed in water at a temperature of 90° or 92° 
for at least half an hour, is highly recommended by some as a sedative. 
The wet pack serves the same purpose, and is more readily applied in 
refractory subjects. 

Judicious nursing is of primary importance. The patient should 
be kept in a cool, well-ventilated, and somewhat darkened room. If 
possible she should remain in bed, or, at least, endeavors should be 
made to restrain the excessive restless motion which has so much effect 
in promoting exhaustion. The presence of relatives and friends, espe- 
cially the husband, has generally a prejudicial and exciting effect; and 
it is advisable to place the patient under the care of nurses experienced 
in the management of the insane, who, as strangers, are likely to have 
more control over her. It is not too much to say that much of the 
success in treatment must depend on the manner in which this indica- 
tion is met. Rough, unskilled nurses, who do not know how to use 
gentleness combined with firmness, will certainly aggravate and pro- 
long the disorder. Inasmuch as no patient should be left unwatched 
by day or night, more than one nurse is essential. 

The question of the removal of the patient to an asylum is one 
which will give rise to anxious consideration. As the fact of having 
been under such restraint of necessity fixes a certain lasting stigma upon 
a patient, this is a step which everyone would wish to avoid if possible. 
In cases of acute mania, which will probably last a comparatively 
short time, home treatment can generally be efficiently carried out. 
Much must depend on the circumstances of the patient. If these be 



PUERPERAL SEPTIC DISEASE. 605 

of a nature which preclude the possibility of her obtaining thoroughly 
efficient nursing and treatment in her own home, it is advisable to 
remove her to a place where these essentials can be obtained, even at 
the cost of some subsequent annoyance. In cases of chronic melan- 
cholia, the management of which is on the whole mere difficulc, the 
necessity for such a measure is more likely to arise, and should not be 
postponed too late. Many examples of incurable dementia arising out 
of puerperal melancholia can be traced to unnecessary delay in placing 
the patients under the most favorable conditions for recovery. 

Treatment during- Convalescence. — When convalescence is com- 
mencing, change of air and scene will often be found of great value. 
Removal to some quiet country place, where the patient can enjoy 
abundance of air and exercise, in the company of her nurses, without 
the excitement of seeing many people, is especially to be recommended. 
Great caution must be used in admitting the visits of relatives and 
friends. In two cases under my own care the patients relapsed, when 
apparently progressing favorably, because the husbands insisted, con- 
trary to advice, on seeing them. On the other hand, Gooch has 
pointed out that when the patient is not recovering, when month after 
month has been passed in seclusion without any improvement, the 
visit of a friend or relative may produce a favorable moral impression 
and inaugurate a change for the better. It is probably in cases of 
melancholia, rather than in mania, that this is likely to happen. The 
experiment may, under such circumstances, be worth trying ; but it is 
one the result of which we must contemplate with some anxiety. 



CHAPTER V. 

PUERPERAL SEPTIC DISEASE. 

Difference of Opinion as to Puerperal Fever. — There is no sub- 
ject in the whole range of obstetrics which has caused so much discus- 
sion and difference of opinion as that to which this chapter is devoted. 
Under the name of puerperal fever , the disease we have to consider has 
given rise to endless controversy. One writer after another has stated 
his view of the nature of the affection with dogmatic precision, often 
on no other grounds than his own preconceived notions and an erro- 
neous interpretation of some of the post-morlem appearances. 



606 • THE PUERPERAL STATE. 

Thus, one states that puerperal fever is only a local inflammation, 
such as peritonitis ; others declare it to be phlebitis, metritis, metro- 
peritonitis, or an essential zymotic disease sui generis, which affects 
lying-in women only. The result has been a hopeless confusion ; and 
the student rises from the study of the subject with little more useful 
knowledge than when he began. Fortunately, modern research is 
beginning to throw a little light upon this chaos. 

Modern View of the Disease. — The whole tendency of recent in- 
vestigation is daily rendering it more and more certain that obstetri- 
cians have been led into error by the special virulence and intensity of 
the disease, and that they have erroneously considered it to be some- 
thing special to the puerperal state, instead of recognizing in it a form 
of septic disease practically identical with that which is familiar to sur- 
geons under the name of pyaemia or septicaemia, generally produced 
by the pathogenic infection of lesions of continuity in the parturient 
canal, resulting from separation of the decidua and placenta, or from 
lacerations of the cervix, vagina, or perineum. 

The term " puerperal fever" therefore, conveying the idea of a 
fever such as typhus or typhoid, must be acknowledged to be mislead- 
ing, and one that should be discarded, as only tending to confusion. 
Before discussing at length the reasons which render it probable that 
the disease is in no way specific or peculiar to the puerperal state, 
it will be well to relate briefly some of the leading facts connected 
with it. 

History. — More or less distinct references to the existence of the 
so-called puerperal fever are met with in the classical authors, prov- 
ing beyond doubt that the disease was well known to them ; and 
Hippocrates, besides relating several cases, the nature of which is un- 
questionable, clearly recognizes the possibility of its originating in the 
retention and decomposition of portions of the placenta. Harvey and 
other writers showed that they were more or less familiar with it, and 
even made most creditable observations on its etiology ; the actual name 
" puerperal fever" was first used by Strother 1 in 1716, but it was not 
until the latter half of the last century that it came prominently into 
notice. At that time the frightful mortality occurring at some of the 
principal lying-in hospitals, especially in the Hotel Dieu at Paris, 
attracted attention, and ever since the disease has been familiar to 
obstetricians. 

Mortality in Lying-in Hospitals. — Its prevalence in hospitals in 
which lying-in women are congregated has been constantly observed 
both in this country and abroad, occasionally producing an appalling 
death-rate ; the disease, when once it has appeared, frequently spread- 
ing from one patient to another in spite of all that could be done to 
arrest it. It would be easy to give many startling instances of this. 
Thus it prevailed in London in the years 1760, 1768, and 1770 to 
such an extent that in some lying-in institutions nearly all the patients 
died. Of the Edinburgh Infirmary, in 1773, it is stated that "almost 
every woman, as soon as she was delivered, or perhaps about twenty- 

1 Criticon Febrium, 1716. 



PUERPERAL SEPTIC DISEASE. 607 

four hours after, was seized with it, and all of them died, though every 
effort was made to care the disorder." Ou the Continent, where the 
lying-in institutions are on a much larger scale, the mortality was 
equally great. Thus in the Maison d'Accouchements of Paris, in a 
number of different years, sometimes as many as 1 in 3 of the women 
delivered died; on one occasion 10 women dying out of 15 delivered. 
Similar results were observed in other great Continental hospitals, as 
in Vienna, where, in 1823, 19 per cent, of the cases died, and in 1842, 
16 per cent. ; and in Berlin, in 1862, hardly a single patient escaped, 
the hospital being eventually closed. 

Such facts, the correctness of which is beyond any question, prove 
to demonstration the great risk which may accompany the aggregation 
of lying-in women. It is to be observed, however, that the cases in 
which the disease produced such disastrous results occurred before our 
more recent knoAvledge of its mode of propagation was acquired, when 
no sufficient hygienic precautions were adopted, when ventilation was 
little thought of, and when, in a word, every condition prevailed that 
would tend to favor the spread of a contagious disease from one patient 
to another. More recent experience proves that, when the contrary is 
the case, the occurrence of epidemics of this kind may be entirely pre- 
vented, and the mortality approximated to that of the best class of 
home practice. The results almost universally obtained of late years 
by the introduction of strict antisepsis into lying-in institutions afford 
a most instructive commentary upon the causes of puerperal fever. 
Thus, in the Maternite, in Paris, the mortality from 1858 to 1870 
was 1 in 11 ; at the present time it is only 1 in 100. At the Foundling 
Hospital in St. Petersburg the mortality before the introduction of 
antiseptics was 1 in 27; since their use 1 in 147. In the General 
Lying-in Hospital, an institution often devastated by puerperal septic 
disease, in five years there was not a single case, and the one death in 
1895 was in a patient admitted in a moribund state from a ruptured 
vagina. Similar satisfactory results have been reported in lying-in 
institutions in Londun, and in America, and indeed universally 
wherever antiseptic precautions have been adopted. 1 There is, indeed, 
no more striking chapter in the history of modern medicine than this. 
Formerly a woman who was delivered in a lying-in hospital ran a risk 
not far short of some of the capital operations ; now she is safer in one 
of them than if she was confined in one of the most sumptuous of 
private houses. 

The more closely the history of these outbreaks in hospitals is studied, 
the more apparent does it become that they are not dependent on any 
miasm necessarily produced by the aggregalion of puerperal patients, 
but on the direct conveyance of septic matter by various means from 
one patient to another. 

Mortality in Private Practice. — It is a painful and not very cred- 
itable fact that the mortality from puerperal septic disease has not 
diminished in private practice as it has in public institutions. This 
has been conclusively shown by Boxall and Cullingworth, the latter 

1 See " The Prevention of Lying-in Fever," by Vanity Sutugin, Edin. Med. Journ., vol. 1884-85 
p. 781. 



608 THE PUERPERAL STATE. 

saying : " We are face to face with the fact that the mortality has not 
apreciably diminished during the past fifteen years, and that the year 
1893 was conspicuous for a puerperal fever mortality only once ex- 
ceeded since 1847. The only possible explanation is that strict anti- 
sepsis is not carried on in private as it is in public practice. It can 
hardly be otherwise when so large a number of parturient women are 
attended by ignorant and untrained mid wives. It may be that the 
older practitioners have not adopted a complete and thorough system 
of antiseptic precautions, but as these are now rigidly insisted on in all 
schools, the number of them will certainly lessen year by year." 1 

In numerous instances the disease has been said to be generally epi- 
demic in domiciliary practice, much in the same way as scarlet fever or 
any zymotic complaint might be. Such epidemics are described as 
having occurred in London in 1827-28, in Leeds in 1809-12, in Edin- 
burgh in 1825, aud many others might be cited. There is, however, 
no sufficient ground for believing that the disease has ever been 
epidemic in the strict sense of the word. That numerous cases 
have often occurred in the' same place and at the same time is 
beyond question ; but this can easily be explained without admitting 
an epidemic influence — knowing, as we do, how readily septic matter 
may be conveyed from one patient to another. In many of the so- 
called epidemics the disease has been limited to the patients of certain 
mid wives or practitioners, while those of others have entirely escaped : 
a fact easily understood on the assumption of the disease being pro- 
duced by septic matter conveyed to the patient, but irreconcilable with 
the view of general epidemic influence. We are not in possession of 
any reliable statistics of the mortality arising from puerperal septi- 
caemia in ordinary general practice. It has, however, been well pointed 
out in the Report on Puerperal Fever, presented by the Obstetrical 
Society of Berlin to the Prussian Minister of Health, 2 that not only 
do the published returns of death from metria afford no reliable esti- 
mate of the actual mortality from this source, but that they are very 
far more numerous than deaths from any other cause in connection 
with pregnancy and childbirth. 

Theories advanced regarding its Nature. — It would be a useless 
task to detail at length the theories that have been advanced to explain 
the disease. Indeed, it may safely be held that the supposed necessity 
of providing a theory which would explain all the facts of the disease 
has done more to surround it with obscurity than even the difficulties 
of the subject itself. If any real advance is to be made, it can only be 
by adopting a humble attitude, by admitting that we are only on the 
threshold of the inquiry, and by a careful observation of clinical facts, 
without drawing from them too positive deductions. 

Theory of its Local Origin. — Many have taught that the disease 
is essentially a local inflammation, producing secondary constitutional 
effects. This view doubtless originated from too exclusive attention 
to the morbid changes found on post-mortem examination. Extensive 

1 " On the Undiminished Mortality from Puerperal Fever in England and Wales," Brit. Med. 
Jour n., March 6, 1897. 

2 " Denkschrift der Puerperalfieber-Commission," Zeitschrift f. Geb. u. Gyn., Band iii. S. 1, trans- 
lated in Edin. Med. Journ., vol. 1878-79. p. 435. 



PUERPERAL SEPTIC DISEASE. 609 

peritonitis, phlebitis, inflammation of the lymphatics or of the tissues 
of the uterus, are very commonly found after death ; and each of these 
has, in its turn, been believed to be the real source of the disease. This 
view rinds but little favor with modern pathologists, and is in so many 
ways inconsistent with clinical facts that it may be considered to be 
obsolete. Xo one of the conditions above mentioned is universally 
found, and in the worst cases definite signs of local inflammation may 
be entirely absent. Nor will this theory explain the conveyance of 
the disease from one patient to another, or the peculiar severity of the 
constitutional symptoms. 

Theory of an Essential Zymotic Fever. — A more admissible 
theory, and one which has been extensively entertained, is that there 
is an essential zymotic fever peculiar to, and only attacking puerperal 
women, which is as specific in its nature as typhus or typhoid, and to 
which the local phenomena observed after death bear the same relation 
that the pustules on the skin do to smallpox, or the ulcers in the 
intestinal glands to typhoid. This fever is supposed to spread by con- 
tagion and infection, and to prevail epidemically both in private and 
in hospital practice. The most recent exponent of this view, Fordyce 
Barker, in his excellent work on the Puerperal Diseases, entered 
at length into all the theories of the disease. He, like all others 
holding his opinions, entirely failed, I cannot but think, to bring 
forward any conclusive evidence of the existence of such a specific 
fever. It is no doubt true that in typhus and typhoid, and other 
undoubted examples of this class of disease, there are well-marked 
local secondary phenomena ; but then they are distinct and constant. 
He makes no attempt to prove that anything of the kind occurs in 
puerperal fever. On the contrary, probably there are no two cases in 
which similar local phenomena occur ; nor is there any case in which 
the most practised obstetrician could foretell either the course and 
duration of the illness or the local phenomena. Again, this theory 
altogether fails to explain the very important class of cases which can 
be distinctly traced to the absorption of septic matter from decompos- 
ing coagula and the like. Barker meets this difficulty by placing such 
cases under a separate category, admitting that they are examples of 
septicaemia. But he fails to show any difference in symptomatology 
or post-mortem signs between them and the cases that he believes to 
depend on an essential fever ; nor would it be possible to distinguish 
the one from the other by either their clinical or pathological history. 

Theory of its Identity with Surgical Septicaemia. — The modern 
view, which holds that the disease is, in fact, identical with the con- 
dition known as pyaemia or septicaemia, is by no means free from 
objections, and much patient clinical investigation is required to give 
a satisfactory explanation of certain peculiarities which the disease 
presents ; but in spite of these difficulties, which time may serve to 
remove, it offers a far better explanation of the phenomena observed 
than any other that has yet been advanced. 

According to this theory, the so-called puerperal fever is produced 
by the absorption of septic matter into the system, through solutions 
of continuity in the generative tract, such as always exist after labor. 

39 



610 THE PUERPERAL STATE. 

It is not essential that the poison should be peculiar or specific .; for, 
just as in surgical pyaemia, any decomposing organic matter may set 
up the morbid action. 

In describing the disease under discussion, I shall assume that, so 
far as our present knowledge goes, this view is the one most consonant 
with facts ; but, bearing in mind that very little is yet known of 
surgical septicaemia, it must not be expected that obstetricians can 
satisfactorily explain all the phenomena they observe. 

The best basis of description I know of is that given by Burdon 
Sanderson, when he says: " In every pyemic process you may trace a 
focus, a centre of origin, lines of diffusion or distribution, and secondary 
results from the distribution. In every case an initial process from 
which infection commences, from which the infection spreads, and 
secondary processes which come out of this primary one/ 7 1 Adopting 
this division, I shall first treat of the mode in which the infection may 
commence in obstetric cases, and point out special difficuties which 
this part of the subject presents. 

Channels through which Septic Matter may be Absorbed. — 
The fact that all recently delivered women present lesions of continuity 
in the generative tract, through which septic matter brought into con- 
tact with them may be readily absorbed, has long been recognized. 
The analogy between the interior of the uterus after delivery and the 
surface of a stump after amputation was first pointed out by Harvey, 
and afterward particularly insisted on by Cruveilhier, Simpson, and 
others — an analogy which was, to a great extent, based on erroneous 
conceptions of what took place — since they conceived that the whole 
interior of the uterus was bared. It is now well known that such 
is not the case ; but the fact remains that at the placental site there are 
open vessels through which absorption may readily take place. 2 That 
absorption of septic material occurs through this channel is prob- 
able in certain cases in which decomposing materials exist in the 
interior of the uterus, especially when, from defective uterine con- 
traction, the venous sinuses are abnormally patulous and are not 
occluded by thrombi. It is difficult to understand how septic matter 
introduced from without can reach the placental site. Other sites 
of absorption are, however, always available. These exist in every 
case in the form of slight abrasions or laceratious about the cervix 
or in the vagina, or, especially in primiparse, about the fourchette and 
perineum. There is even some reason to think that absorption of 
septic matter may take place through the mucous membrane of the 

1 Clinical Transactions, vol. vii. p. 108. 

2 At any rate this analogy is an approach to the identity in this respect of a puerperal and a 
surgical patient, which is the essential fact in the interpretation of septic disease in childbirth. 
The practical identity of surgical and puerperal septicaemia was very clearly pointed out by Sir 
James Simpson in his'interesting paper '• On the Analogy between Puerperal and Surgical Fever." 
published in 1850, which was far in advance of the teaching of the day. It is interesting to note 
how he foreshadowed the enormous gains both to surgery and midwifery which have followed the 
general adoption of the principles of antisepticism. "I do believe," he says, " that if any man 
should ever have the good fortune to detect or suggest any simple and practical measures to avert 
and prevent or to mitigate and cure surgical or puerperal'fever, he would, in doing so, confer one 
of the greatest of all possible benefits upon the advancement of surgery and midwifery, and be the 
means of saving numerous lives in operative and obstetric practice. iS'or does it seem utterly 
hopeless to expect the possible detection of some such measures in the way of prevention, at least, 
if not in the way of cure." Happily the man has been found, with the results, as regards both 
surgery and midwifery, which Simpson predicted and all the world knows. 



PUERPERAL SEPTIC DISEASE. 611 

vagina or cervix without any breach of surface. This might serve 
to account for the occasional, though, rare, cases in which the symptoms 
of the disease develop themselves before delivery, or so soon after it as 
to show that the infection must have preceded labor ; nor is there any 
inherent improbability in the supposition that septic material may be 
occasionally absorbed through the unbroken mucous membrane, as is 
certainly the case with some poisons, for example that of syphilis. 
Hence there is no difficulty in recognizing the similarity of a lying-in 
woman to a patient suffering from a recent surgical lesion, or in under- 
standing how septic matter conveyed to her, during or shortly after 
labor, may be absorbed. It is necessary, however, to suppose that 
absorption takes place immediately or very shortly after these lesions 
of continuity arc formed, for it is well known that the power of absorp- 
tion is arrested after they have commenced to heal. This fact may 
explain the cases in which sloughing about the perineum or vagina 
exists without any septicaemia resulting, or the far from uncommon 
cases in which an intensely fetid lochial discharge may be present a 
few days after delivery without any infection taking place. 

The character and sources of the septic matter constitute one of the 
most obscure questions in connection with septicemia, and that which 
is most open to discussion. 

Division into Autogenetic and Heterogenetic Cases. — A popular 
division of the subject has been into cases in which the septic matter 
originates within the patient, so that she infects herself, the disease 
then being mitogenetic ; and into those in which the septic matter is 
conveyed from without and brought into contact with absorptive sur- 
faces in the generative tract, the disease then being heterogenetic. 

The term autogenetic has been properly objected to on the ground 
that retained coagula and the like, contained within the person of the 
patient, would not of themselves decompose and give rise to infection 
unless microbes had found their way to them from without and set up 
decomposition. In this strict sense the word may be admitted to be 
inaccurate. At the same time the division was a very practical one, 
and it laid stress on the danger of leaving organic structures, such as 
portions of placenta, membranes, or clots, within the genital tract. 
With this explanation, therefore, the division may be retained. It is 
supposed that disease of this type originates from saprsernic intoxication 
due to the absorption of poisonous materials resulting from putrefactive 
changes, but that it differs from the septic infection, inasmuch as 
organisms do not invade the tissues and multiply in them. Clinically, 
however, the two types of disease cannot be distinctly differentiated, 
and it is admitted that they may be combined, true pathogenic mi- 
crococci finding a congenial soil in the decomposing structures, and 
subsequently invading the tissues. The former class of disease may be 
termed saprcemia, corresponding to cases which have been described as 
autoo:enetic ; the latter septiccemia, corresponding to the heterogenetic 
type. 

Can autoinfection occur? Since micro-organisms are known to exist 
in the vagina under normal conditions, the question whether they might 
not infect the patient after delivery and produce what might strictly be 



612 THE PUERPERAL STATE. 

called "autogenetic " septic disease has been hotly discussed. Theoreti- 
cally this may be admitted to be possible ; practically it is not. The nor- 
mal vaginal secretions are held to have a germicidal effect, and the en- 
deavor to prevent septicaemia by repeated antiseptic douching is recog- 
nized as useless. In a large number of lying-in institutions in Germany 
they have been discontinued, reliance being placed on thorough clean- 
liness of hands, instruments, etc., and in the avoidance as much as 
possible of needless vaginal examinations, so as to minimize the risk 
of the introduction of pathogenic organisms from without, with the 
result that the number of febrile cases has been considerably lessened. 
Sources of Saprsemia or Self-infection. — The sources of saprsemia 
may be various, but they are not difficult to understand. Any condi- 
tion giving rise to decomposition, either of the tissues of the mother 
herself, of matters retained in the uterus or vagina that ougnt to have 
been expelled, or decomposing matter derived from a putrid foetus, may 
start the saprsemic process. Thus it may happen that from continuous 
pressure on the maternal soft parts during labor, sloughing has set in ; 
or there may be already decomposing material present from some 
previous morbid state of the genital tract, as in carcinoma. A more 
common origin is the retention of coagula, or of small portions of mem- 
brane, or of placenta, in the interior of the uterus, which have putrefied 
from access of air ; or in the decomposition of the lochia. It was sug- 
gested long since that the disease might be due to the absorption of 
animal poisons after delivery, and a subsequent vitiation of the blood ; 
as, for example, by Kirkland, 1 who wrote in 1874, " It sometimes 
happens that coagulated blood lodges in the uterus after delivery, and, 
putrefying from access of air, forms an active poison, is in part absorbed 
and brings on putrid fever/' But such passing surmises attracted 
little attention. That the retention of portions of the placental tissue 
has at all times been the cause of septic disease may be illustrated 
by the case of the Duchesse d'Orleans (in the time of Louis XIII.), 
who had an easy labor, but died of childbed fever. An examination 
was made by the leading physicians of Paris, in their report of which 
it was stated : " On the right side of the womb was found a small 
portion of afterbirth, so firmly adherent that it could hardly be torn 
off by the finger-nails." 2 The reason why self-infection does not more 
often occur from such sources, since more or less decomposition is of 
necessity so often present, has already been referred to in the fact that 
absorption of such matters is not apt to occur when the lesions of con- 
tinuity, always existing after parturition, have commenced to heal. 
This observation may also serve to explain how previous bad states of 
health, by interfering with the healthy reparative process occurring after 
delivery, may predispose to self-infection. Kanthack 3 has conclusively 
shown how readily transient conditions, such as are very apt to occur in 
connection with pregnancy and childbirth, may increase the tendency to 
infection. It is interesting to note that puerperal saprsemia, arising from 
such sources, is not limited to the human race. In the debate on pyasmia 

i " On Childbed Fever," London, 1774. 

2 .Louise Bourgeois, by Goodell. 

3 Allbutt's " System of Medicine," vol. i. p. 549. 



PUERPERAL SEPTIC DISEASE. 613 

at the Clinical Society, Mr. Hutchinson recorded several well-marked 
examples occurring in ewes, in whose uteri portions of retained placenta 
were found. 

Source of He tero genetic Infection. — The sources of septic matter 
conveyed from without are much more difficult to trace, and there are 
many facts connected with heterogenetic infection which are very diffi- 
cult to reconcile with theory, and of which, it must be admitted, we 
are not yet able to give a satisfactory explanation. 

It is probable that any decomposing organic matter may infect, but 
that some forms operate with more certainty and greater virulence 
than others. 

One of these, which has attracted special attention, is what may be 
termed cadaveric poison, derived from dissection of the dead subject 
in the anatomical and post-mortem theatres, and conveyed to the 
genital tract by the hands of the accoucheur. Attention was particu- 
larly directed to this source of infection by the observations of Seni- 
melweiss, who showed that in the division of the Vienna Lying-in 
Hospital attended by medical men and students who frequented the 
dissecting-rooms the mortality was seldom less than one in ten, while 
in the division solely attended by women the mortality never exceeded 
one in thirty-four; the number of deaths in the former division at 
once falling to that of the latter so soon as proper precautions and 
means of disinfection were used. Many other facts of a like nature 
have since been recorded which render this origin of puerperal septi- 
caemia a matter of certainty. An interesting example is related by 
Simpson with characteristic candor: "In 1836 or 1837, Mr. Sidey, of 
this city, had a rapid succession of five or six cases of puerperal fever 
in his practice, at a time when the disease was not known to exist in 
the practice of any other practitioners in the locality. Dr. Simpson, 
who had then no firm or proper belief in the contagious propagation 
of puerperal fever, attended the dissection of Mr. Sidey's patients 
and freely handled the diseased parts. The next four cases of mid- 
wifery which Dr. Simpson attended were all affected with puerperal 
fever, and it was the first time he had seen it in practice. Dr. Patter- 
son, of Leith, examined the ovaries, etc. The next three cases which 
Dr. Patterson attended in that town were attacked witli the disease." 1 
Negative examples are of course brought forward, of those who have 
attended post-mortem examinations without injury to their obstetric 
patients, which merely prove that the cadaveric poison does not, of 
necessity, attach itself to the hands of the dissector; no amount of 
such testimony can invalidate such positive evidence as that just 
narrated. Barnes believes that there is not so much danger attending 
the dissection of patients who have died of any ordinary disease, but 
that the risk attending the dissection of those who have died of infec- 
tious or contagious complaints is very great indeed. 2 I presume there 
is no doubt that the risk is greater when the subject has died from 
zymotic disease; but the distinction is too delicate to rely on, and the 
attendant on midwifery will certainly err on the Bafe side by avoiding 

' Selected Obstetric Works. | 

2 •■ Lectures on Puerperal Fever " Lancet, 1865, vol. ii. p. 112. 



614 THE PUERPERAL STATE. 

as much as possible having anything to do with the conduct of dissec- 
tions or post-mortem examinations. 

Infection from Erysipelas. — Another possible source of infection 
is erysipelatous disease in all its forms. The intimate connection 
between erysipelas and surgical pyaemia has long been recognized by 
surgeons, and the influence of erysipelas in producing puerperal septi- 
caemia has been specially observed in surgical hospitals into which 
lying-in patients were also admitted. Trousseau relates instances of 
this kind occurring in Paris. The only instance that I know of in 
London was in the lying-in ward of King's College Hospital, where, 
in spite of every hygienic precaution, the mortality was so great as to 
necessitate the closure of the ward. Here the association of erysipelas 
with puerperal septicaemia was again and again observed; the latter 
proving fatal in direct proportion to the prevalence of the former in 
the surgical wards. The dependence of the two on the same poison 
was in one instance curiously shown by the fact of the child of a 
patient who died of puerperal septicaemia dying from erysipelas which 
started from a slight abrasion produced by the forceps. A more 
recent and very remarkable example is related by Dr. Lombe Atthill. 1 
A patient suffering from erysipelas was admitted into the Rotunda 
Hospital on February 15, 1877. The sanitary condition of the hos- 
pital was at the time excellent. The patient was removed next day, 
but of the next 10 patients confined in adjoining wards, 9 were attacked 
with puerperal peritonitis, the only one who escaped being a case of 
abortion. But the connection between erysipelas and puerperal septi- 
caemia is not limited to hospitals, having been observed in domiciliary 
practice. Some interesting facts have been collected by Dr. Minor, 2 
who has shown that the two diseases have frequently prevailed 
together in various parts of the United States, and that during an out- 
break of puerperal fever in Cincinnati it occurred chiefly in the practice 
of those physicians who attended cases of erysipelas. Many children 
also died from erysipelas whose mothers had died from puerperal fever. 

Infection from other Zymotic Diseases. — There is good reason to 
believe that the contagium of other zymotic diseases may produce a 
form of disease indistinguishable from ordinary puerperal septicaemia, 
and presenting noue of the characteristic features of the specific com- 
plaint from which the contagium was derived. This is admitted to 
be a fact by the majority of our most eminent British obstetricians, 
although it does not seem to be allowed by Continental authorities, and 
it is strongly controverted by some writers in this country, who, how- 
ever, come under the suspicion of trying to shut their eyes to facts 
which do not fit in with their own theories. To me it seems to be 
more scientific to admit the facts, if they are well observed and reliable, 
and to reconcile the theories with them, rather than to reconcile the facts 
to the theories. I believe, however, that the evidence in favor of the 
possibility of puerperal septicaemia originating in this way is too strong 
to be assailable. 

The scarlatinal poison is that regarding which the greatest number 

1 Medical Press and Circular, January-June, 1877, p. 339. 

2 Erysipelas and Childbed Fever. Cincinnati, 1874. 



PUERPERAL SEPTIC DISEASE. 615 

of observations have been made. Numerous cases of this kind are to 
be found scattered through our obstetric literature, but the largest 
number are to be met with in a paper by Dr. Braxton Hicks in the 
twelfth volume of the Obstetrical Transactions, and they are especially 
valuable from that gentleman's well-known accuracy as a clinical 
observer. Out of 68 cases of puerperal disease seen in consultation, 
no less than 37 were distinctly traced to the scarlatinal poison. Of 
these 20 had the characteristic rash of the disease ; but the remaining 
17, although the history clearly proved exposure to the contagium of 
scarlet fever, showed none of its usual symptoms, and were not to be 
distinguished from ordinary typical cases of the so-called puerperal 
fever. On the theory that it is impossible for the specific contagious 
diseases to be modified by the puerperal state, we have to admit that 
one physician met with 17 cases of puerperal septicaemia in which, by 
a mere coincidence, the contagion of scarlet fever had been traced, 
and that the disease nevertheless originated from some other source 
— an hypothesis so improbable that its mere mention carries its own 
refutation. 

With regard to the other zymotic diseases the evidence is not so 
strong ; probably from the comparative rarity of the diseases. Hicks 
mentions one case in which the diphtheritic poison was traced, although 
none of the usual phenomena of the disease were present. I lately 
saw a case in which a lady, a few days after delivery, had a very 
serious attack of septicaemia, without any diphtheritic symptoms, her 
husband being at the same time attacked with diphtheria of a most 
marked type. Here it would be difficult not to admit the dependence 
of the two diseases on the same poisou. Haultaiu 1 has published a very 
interesting case in which the diphtheritic character of the poison was 
proved to demonstration by cultures of the blood and of the uterine 
discharges showing pure typical cultures of the Loffler bacillus, the 
symptoms not having given rise to the suspicion that the case was 
other than an ordinary example of puerperal septicaemia. Moreover, 
the injection of anti-diphtheriiic antitoxin proved rapidly beneficial. 

It is, however, certain that all the zymotic diseases may attack a 
newly delivered womau, and run their characteristic course without 
any peculiar intensity. Probably most practitioners have seeu cases 
of this kind; and this is precisely one of the points of difficulty which 
we cannot at present explain, but on which future research may be 
expected to throw some light. It seems to me not improbable that the 
explanation of the fact that zymotic poison may, in one puerperal 
patient, run its ordinary course, and in another produce symptoms of 
intense septicaemia, may be found in the channel of absorption. It is, 
at any rate, comprehensible that if the contagium be absorbed through 
the skin or other ordinary channel, it may produce its characteristic 
symptoms and run its usual course; while, if brought into contact with 
lesions of continuity in the generative tract, it may act more in the 
way of septic poison, or with such intensity that its specific symptoms 
are not developed. It is interesting to observe in this connection, and 

« Edin Med. Journ , August. 1^97. 



616 THE PUERPERAL STATE. 

the fact may afterward help to clear up this difficult question, that 
bacteria obtained from cultivations made from undoubted scarlet fever 
cases are indistiuguishable from the streptococcus obtained from cul- 
tures taken from unquestionable cases of puerperal septicaemia 1 . 

It may reasonably be objected that if puerperal and surgical sep- 
ticaemia be identical, the zymotic poisons ought to be similarly modi- 
tied when they infect patients after surgical operations. The subject 
of specific contagium as a cause of surgical pyaemia has been so little 
studied, that I do not think anyone would be justified in asserting that 
such an occurrence is not possible. Fritsch, of Halle, and other 
German physicians have recently shown how elaborate antiseptic pre- 
cautions in lying-in hospitals may prevent the origin of the disease 
from such sources. Sir James Paget, in his Clinical Lectures, seems 
to believe in the possibility of such modification. He says : " I think 
it not improbable that, in some cases, results occurring with obscure 
symptoms, within two or three days after operations, have been due to 
scarlet- fever poison, hindered in some way from its usual progress." 
Sir Spencer Wells informed me that he had seen cases of surgical pyaemia 
which he had reason to believe originated in the scarlatinal poison ; 
and his well-known success as an ovariotomist was, no doubt, in a great 
measure to be attributed to his extreme care in seeing that no one 
likely to come in contact with his patients had been exposed to any 
such source of infection. 

Conveyance of Infection in the Atmosphere. — Of late years 
there has been a tendency on the part of obstetricians to limit the causes 
of puerperal infection to pathogenic matter conveyed directly on the 
hands, instruments, and the like, and to minimize the influence of con- 
tagion conveyed in any other way. There appears, however, to be 
strong clinical evidence that infective material suspended in the atmos- 
phere may reach the patient by some other means than by direct convey- 
ance. Amand Routh, in a discussion on this matter at the Obstetrical 
Society, referred to a case occurring in the wife of a butcher confined 
over the shop. I have myself been called in to no less than three such 
cases in butchers' wives. In some of these the odor of meat permeated 
the whole house. Is it not probable that infective germs, similar to 
those which convey the contagion in the case of students engaged in 
dissection, were widely diffused, and that no lying-in woman is safe in 
such an atmosphere ? 

Sewer-gas and Defective Sanitary Arrangements. — Exposure to 
sewer-gas may, I feel sure, produce a form of septic disease which I 
have not been able so far to distinguish from puerperal septicaemia. 
In two cases of the kind I had the opportunity of closely watching an 
untrapped drain opened directly into the bedroom — in one instance 
into a bath, in the other into a water-closet. Both cases were indis- 
tinguishable from the ordinary form of the disease, and in both im- 
provement commenced as soon as the patient was removed into another 
room. 

In a case I saw some years ago at Notting Hill, the patient, who 

1 Crookshank : " Bacterilogy of Infective Diseases, " p. 262 



PUERPERAL SEPTIC DISEASE. 617 

had been confined within a week, had ail the symptoms of a most in- 
tense attack of septicaemia, but none of a diphtheritic character, while 
her husband lay in an adjoining room suffering from a diphtheritic 
sore-throat. Here the waste-pipe of the bath was found to communi- 
cate directly with the sewer. In spite of her intense illness, I had the 
patient removed to another house, and from that moment she began to 
improve. In two other cases in which the same source of disease was 
detected, the removal of the patient from the infected atmosphere was 
immediately followed by a marked amelioration in the symptoms. I 
know of three similar cases which ended fatally, in which I have every 
reason to believe that the cause of the disease was poisoning by sewer- 
gas. Frankenhauser has related a curious case of the poisoning of four 
puerperal women by sewer-gas. Gustave Braun 1 ascribes a recent mor- 
tality in his clinic of 8.87 per cent, to bad sewerage, his wards being in 
direct connection with the sewerage system of the General Hospital, 
and near the closets of the adjoining barracks. Technical antisepsis 
had been as faithfully practised as is possible where instruction has 
been given to midwives. Gueniot has also' published a number of 
interesting cases of the kind, and it appears to be beyond doubt that 
there is a fertile source of dangerous illness in lying-in women, which 
has never yet been clinically distinguished from puerperal septicaemia 
due to mauual and like conveyance. Are we justified in asserting, as 
some seem inclined to assume, that this illness is something entirely dif- 
ferent from septicaemia, simply because they do not admit that patho- 
genic microbes can be suspended in the atmosphere as well as attached 
to examining fingers ? It has been suggested that as the air of sewers 
has been proved to be bacteriological ly pure, these cases may be ex- 
plained on the supposition that sewer-air alone does not cause septi- 
caemia, but produces, possibly by some unrecognized ptomain contained 
in it, a condition peculiarly favorable to the absorption aud growth of 
pathogenic germs after delivery. This hypothesis would account for 
cases, otherwise difficult to explain, in which women who have been 
exposed for a length of time to sewer emanations without apparent 
mischief show signs of septic disease as soon as labor has taken place. 2 
Septicaemia from Contagion Conveyed. — The last source from 
which septic matter may be conveyed is from a patient suffering from 

i Centralblatt fur Gyniik.. No. 36. 

2 I have been favored with an interesting letter on the subject from Dr. Nariman, a well-known 
Parsee practitioner in Bombay. In this he says: "From some supjwDsed religious prejudices 
(though our sacred writings do not say a word about it) our females are always confined on the 
ground floor, in many cases having their bed near the mouth of the drains, the drainage system 
being very imperfect." A perusal of the accompaning paper will convince you that the view's you 
propound in your address published in the Lancet of Feb. 5, 1887, are fully corroborated by my 
own experience, which is particularly of value to prove sewer-gas to be one of the causes of puer- 
peral fevers. I have observed numberless cases in which the cause of puerperal septicseraia could 
be distinctly traced to sewer gas alone." 

Since the above was written, I have published a special paper on this subject ("Defective Sani- 
tation as a Cause of Puerperal Disease." I append from it two cases, as I think the diagrams illus- 
trating this source of danger may prove of interest : 

The annexed diagram (Fig. 196) represents a bedroom in a large house in a fashionable part of 
the West End, which had been recently taken and done up in the most costly way. I attended 
the lady of the house in her second confinement, and she lay in her bed at a. Shortly she developed 
well-marked septic symptoms, and I naturally investigated the sanitary state of the nous 
if it threw any light" on their origin. I could find nothing amiss. There was no bath or fixed 
washstand near the room, and the closets were at a distance, with the soil-pipe running down 
the outside wall, as it should do. It was not until some days afterward that I discovered the 
extraordinary arrangement depicted in the diagram, which no one could possibly have suspected, 
and the knowledge of which the patient bad given special directions should be withheld from 
me. At b is represented a very handsome and innocent-looking piece of furniture which seemed 



618 



THE PUERPERAL STATE, 



puerperal septicaemia, a mode of origin which has, of late, attracted 
special attention. That this is the explanation of the occasional 
endemic prevalence of the disease in lying-in hospitals can scarcely be 
doubted. The theory of a special puerperal miasm pervading the 
hospital is not required to account for the facts, for there are a hun- 
dred ways, impossible to detect or avoid — on the hands of nurses or 
attendants, in sponges, bedpans, sheets, or even suspended in the 
atmosphere — in which septic material derived from one patient may 
be carried to another. 

The poison may be conveyed in the same manner from one private 
patient to another. Of this there are many lamentable instances recorded. 
Thus it was mentioned by a gentleman at the recent discussion at the 
Obstetrical Society, that five out of fourteen women he attended died, 
no other practitioner in the neighborhood having a case. This origin 
of the disease was clearly pointed out by Gordon toward the end of 
last century, who stated that he himself " was the means of carrying 



Fig. 196. 




BED ROOM 



to be a fixed wardrobe, to which p.urpose its ends were in fact devoted. The centre door, how- 
ever, formed by a large mirror, opened on a concealed water-closet (c), which luxury no one could 

have looked for in such a situation. I subsequently 
discovered that this was a brilliant idea of the hus- 
band's, who actually had had a special soil-pipe 
carried through the centre of the house, which com- 
municated directly with the main drain, with no 
ventilation, and who had thus contrived, at an enor- 
mous cost, to have a stream of sewer-gas laid on 
close to his bedside. And be it remarked that 
builders and plumbers had carried out this inge- 
niously dangerous arrangement without giving the 
slightest hint that it was either unusual or perilous. 
Of course, as soon as I made this discovery I had the 
patient removed to another room, when her symp- 
toms soon abated. 

I could easily go on multiplying examples of this 
kind, but I shall content myself with one more case, 
which was thoroughly worked out, Avith very in- 
structive results. It was that of a lady who was 
confined of her first child, in the country in a large 
and expensive house, newly built, and supposed to 
be supplied with all the most perfected sanitary 
arrangements. There was nothing particular about 
the labor, and for the first ten days the convalescence 
left nothing to be desired. On the eleventh day she 
got up and lay on the sofa (Fig. 197, d) opposite the 
fire (F), which, as it was in January, was burning 
day and night. The day after, although she had a 
headache and felt poorly, she again got up and lay 
on the sofa. The subsequent day, although feeling 
very ill, she again insisted on getting up, and lay 
on the sofa at E, in her husband's dressing-room. 
On the following day she was very ill indeed, with 
a temperature of 104° and a pulse of 130, and I was 
summoned to see her. It is needless to say more of 
her illness, which rapidly increased, except that, 
feeling satisfied it was caused by defective sanita- 
tion, I advised her removal to a house in the neigh- 
borhood, in spite of the very grave symptoms that 
existed, with the most satisfactory result, for within 
twenty-four hours her temperature had fallen, and 
she rapidly became convalescent. Of course, at this 
time nothing was known of what actually existed, 
but I was led to form this conclusion from the fact that a number of the servants and residents were 
suffering from sore-throats, and from being told that almost everyone who came to stay felt ill and 
out of sorts. Subsequently the sanitary state of the house was thoroughly investigated by one of the 
most distinguished sanitary engineers in London, from whose reports the accompanying diagram 
(Fig. 197) is copied. It is useless to enter into a description of all the abominations w r hich were 
found to exist, which, in a house of the kind, in the building of which no expense was spared, 
were almost past belief. For the purpose of my story it will suffice to say that the smoke test 
showed that there was a very abundant escape of sewer-gas in both the bedroom and dressing- 
room, which, from the fact that there were large fires burning constantly in both rooms, passed 
in a continuous current in the direction of the arrows. In addition, the plumbing-work in the 
closet, B, in the dressing-room, had been so imperfectly done that its contents found their way out 
under the floor, e. Now, mark how thoroughly and curiously these facts prove the cause of the 
disease. The patient lay in the bed at c, which, from tne accident of its being winter, and the 




PUERPERAL SEPTIC DISEASE 



619 



the infection to a great number of women," 1 and he also traced the 
spread of the disease in the same way in the practice of certain mid- 
wives. In some remarkable instances the unhappy property of carry- 
ing contagion has clung to individuals in a way which is most 
mysterious, and which has led to the supposition that the whole system 
becomes saturated with the poison. One of the strangest cases of this 
kind was that of the late Dr. Rutter, of Philadelphia, which caused 
much discussion. He had forty-five cases of puerperal septicaemia in 
his own practice in one year, while none of his neighbors' patients were 
attacked. Of him it is related : " Dr. Rutter, to rid himself of the 
mysterious influence which seemed to attend upon his practice, left the 
city for ten days, and before waiting on the next parturient case had 
his hair shaved off and put on a wig, took a hot bath, and changed 
every article of his apparel, taking nothing with him that he had worn 
or carried, to his knowledge, on any former occasion : and mark the 
result. The lady, notwithstanding that she had an easy parturition, 

current of sewer-gas being drawn therefore to the chimneys, was quite out of its reach, and for 
the first ten days after her confinement, while she remained in bed, she was perfectly well. On 
the eleventh day. when she got up, she was placed directly in the current of sewer-gas at r>, and 
instantly got poisoned. On the twelfth and thirteenth days she was again exposed to the absorp- 
tion of further and more intense poisoning, at e ; while immediately on her removal to fresh and 

Fig. 197. 




uncontaminated air all her threatening symptoms disappeared. Remark also that there was 
nothing peculiar in the svmptomatology. nothing different from an ordinary and rapidly progress- 
ing case of puerperal septicaemia. It seems to me that thi- instructive history is about as complete 
a demonstration of the origin of puerperal disease from defective sanitation as anyone could pos- 
sibly desire, and I can see no flaw in the chain of evidence. 
1 See Lectures on Puerperal Fever. By Robert J. Lee, M.D. 



620 THE PUERPERAL STATE. 

was seized the next day with childbed fever, and died on the eleventh 
day after the birth of the child. Two years later he made another 
attempt at self-purification, and the next case attended fell a victim to 
the same disease." No wonder that the late Charles D. Meigs, in 
commenting on such a history, refused to believe that the doctor car- 
ried the poison, and rather thought " that he was merely unhappy in 
meeting with such accidents through God's providence." It appears, 
however, that Dr. Rutter was the subject of a form of ozsena, and it is 
quite obvious that, under such circumstances, his hands could never 
have been free from septic matter. 1 This observation is of peculiar 
interest as showing that the sources of infection may exist in conditions 
difficult to suspect and impossible to obviate, and it affords a satis- 
factory explanation of a case which was for years considered puzzling 
in the extreme. It is quite possible that other similar cases, of which 
many are on record, although none so remarkable, may possibly have 
depended on some similar cause personal to the medical attendant or 
nurse. 

Proby 2 suggests that a similar source of infection may occasionally 
be found in a carious tooth or alveolar abscess, the pus infecting the 
examining finger. 

The sources of septic poison being thus multifarious, a few words 
may be said here as to the mode in which it may be conveyed to the 
patient. 

Mode in -which the Poison may be Conveyed to the Patient. — 
As on the view of puerperal septicaemia which seems most to agree 
with recorded facts, the poison, from whatever source it may be derived, 
must come into actual contact with lesions of continuity in the genera- 
tive tract, it is obvious that one method of conveyance may be on the 
hands of the accoucheur. That this is a possibility, and that the dis- 
ease has often been unhappily conveyed in this way, no one can doubt. 
Still it would be unfair in the extreme to conclude that this is the only 
way in which infection may arise. In town practice, especially, there 
are many other ways in which septic matter may reach the patient. 
The nurse may be the means of communication, and if she has been in 
contact with septic matter she is even more likely than the medical 
attendant to convey it when washing the genitals during the first few 
days after delivery, the time at which absorption is most apt to occur. 
Barnes relates a whole series of cases occurring in a suburb of London, 
in the practice of different practitioners, every one of which was 
attended by the same nurse. Again, septic matter may be carried in 
sponges, linen, and other articles. What is more likely, for example, 
than that a careless nurse might use an imperfectly washed sponge, on 
which discharge has been allowed to remain and decompose ? Nor do 

1 This is stated on the authority of an obstetrical contemporary of Dr. Rutter. See Amer. Journ. 
of Med. Sciences, 1875, vol. lxix. p. 474. (Minor.) 

The author quotes from the editor. Dr. Rutter had an ozsena which in time much disfigured 
him from its effect upon the contour of his nose. He was unfortunately inoculated in his index 
finger from a patient, and neglected the pustule. He had ninety -five cases of puerperal septicemia 
in four years and nine months, with eighteen deaths. The question of Dr. Meigs, who was a non- 
contagionist in regard to puerperal peritonitis, was remarkably apposite : " Did he distil a subtle 
essence which he carried with him?"— Harris's note to the third American edition. 

2 Lancet, December 21, 1889. 



PUERPERAL SEPTIC DISEASE. 621 

I see any reason to question the possibility of infection from septic 
matter suspended in the atmosphere ; and in lying-in hospitals, where 
many women are congregated together, there can be little doubt that 
this is a common origin of the disease. It is certain, whatever view 
we may take of the character of the septic material, that it must be in 
a state of very minute subdivision, and there is no theoretical difficulty 
in the assumption of its being conveyed by the atmosphere. 

Conduct of the Practitioner in Relation to the Disease. — This 
question naturally involves a reference to the duty of those who are 
unfortunately brought into contact with septic matter in any form, 
either in a patient suffering from puerperal septicaemia, zymotic dis- 
ease, or offeusive discharges. The practitioner cannot always avoid 
such contact, and it is practically impossible to relinquish obstetric 
work every time that he is in attendance on a case from which con- 
tagion may be carried. Xor do I believe, especially in these days 
when the use of antiseptics is so well understood, that it is essential. 
It was otherwise when antiseptics were not employed ; but I can 
scarcely conceive any case in which the risk of infection cannot be 
prevented by proper care. The danger I believe to be chiefly in not 
recognizing the possible risk, and in neglecting the use of proper pre- 
cautions. It is impossible, therefore, to urge too strongly the necessity 
of extreme and even exaggerated care in this direction. The prac- 
titioner should accustom himself, as much as possible, to use the left 
hand only in touching patients suffering from infectious diseases, as 
that which is not used, under ordinary circumstances, in obstetric 
manipulations. He should be most careful in the frequent employ- 
ment of antiseptics in washing his hands, such as the 1 : 1000 solution 
of perchloride of mercury. Clothing should be changed on leaving an 
infectious case. Much more care than is usually practised should be 
taken by nurses, especially in securing perfect cleanliness in everything 
brought into contact with the patient. When, however, a practitioner 
is in actual and constant attendance on a case of puerperal septicaemia, 
when he is visiting his patient many times a day, especially if he be 
himself washing out the uterus with antiseptic lotions, it is certain that 
he cannot deliver other patients with safety, and he should secure the 
assistance of a brother practitioner, although there seems no reason 
why he should not visit women already confined, in whom he has not 
to make vaginal examinations. 

Prophylaxis of Septicaemia. — If the views here inculcated as to 
the nature and the mode of infection in puerperal septicaemia be correct, 
it is obvious that much may be done in the way of prophylaxis. A 
perfectlv aseptic management of puerperal women is practically impos- 
sible. In most lying-in institutions very rigid rules arc now laid down 
to prevent the possibility of infective matter being conveyed to the 
patient either on the hands of the attendants, or on instrument-, 
napkins, and the like, and with the most satisfactory results. As the 
risk is much greater when lying-in women are collected together, such 
precautions, which this is not the place to discuss, are absolutely indi- 
cated. They are not, however, easily applicable in ordinary private 
practice; but there are certain simple precautions which everyone 



622 THE PUERPERAL STATE. 

might adopt without trouble, which will materially lessen the risk of 
septic poisoning. Among these may be indicated the use of soap and 
water and of antiseptic lotions, with which the practitioner and nurse 
should always wash their hands before attending any case or touching 
the genital organs ; the use of carbolized vaseline, 1 : 8, for lubricating 
the ringers, catheter, forceps, etc.; syringing out the vagina night and 
morning with creolin and water ; rigid attention to cleanliness in bed- 
ding, napkins, etc. Precautions such as these, although they may 
appear to some frivolous and useless, indicate a recognition of danger 
and an endeavor to remove it, and if they were generally inculcated on 
nurses (see note, p. 567) and others, might go far to prevent the oc- 
currence of septic mischief. 

Nature of the Septic Poison. — As to the precise character of the 
septic poison — although of late much has been said about it, and there is 
good reason to believe that further research may throw light on this 
obscure subject — too little is known to justify any positive statement. 
Numerous observers have shown that in puerperal septicaemia, as in sur- 
gical fever, erysipelas, and other iufectious diseases, micrococci in large 
numbers may be traced passing between the muscular and connective- 
tissue fibres, through the lymphatics, and thus into the general circula- 
tion, and that they may be found in various organs and pathological 
products. Frankel isolated from a number of cases a chain-forming 
micrococcus, which he at first regarded as specific, and named the 
streptococcus puerperalis (Plate VII., Fig. 1). Subsequently he 
satisfied himself of its identity with a similar micro-organism in pus 
(Plate VII., Fig. 3). Winckel also cultivated a streptococcus from 
a case of puerperal peritonitis. It produced an erysipelatous rash in 
the ear of a rabbit, and was similar in its characters, both morpholog- 
ically and in artificial cultivations, to the streptococcus found in ery- 
sipelas. Cushing found streptococci in endometritis diphtheritica and 
in secondary puerperal inflammation, and Baumgarten, Bumm, Pfan- 
nestiel, and others have recorded similar observations. Pfannestiel 
investigated four cases of puerperal septicaemia with diphtheritic 
endometritis and purulent peritonitis, and he concluded that a specific 
micro-organism could not be differentiated in puerperal fever. In his 
opinion the streptococci from pus, from erysipelas, and diphtheritic 
affections of the pharynx had all the power of setting up puerperal sep- 
ticemia. Doleris never failed to find streptococci in the blood in puer- 
peral septicaemia, and after death they are readily detected in great num- 
bers. It may be taken for granted that in the acute form of septicaemia 



PLATE VII. 
Illustrations of Streptococci. 

Fig. 1. Sections through the decidua and adjacent muscular walls in a case of acute puerperal 
septicaemia. Streptococci growing between the muscular fibres. (After Bumm.) 

Fig. 2. Section through the decidua removed by the curette in a case of puerperal endometritis. 
A necrosed layer of decidua infiltrated with putrefactive germs (6). Reaction layer showing nuclei 
of the leucocytes. (After Bumm.) 

Fig. 3. Streptococcus pyogenes from a pysemic abscess. (After Crookshank.) 



PLATE VII. 



Fig. I 








,. "*u. 



\ 



Illustrations of Streptococci 



PUERPERAL SEPTIC DISEASE. 623 

without local complications, streptococci form the infective agents. They 
do not multiply in the blood during life, but they cause changes in both 
the red and white corpuscles, which stick together and form minute 
capillary infarctions, in which the micrococci increase, and from which 
they invade the surrounding structures and produce various patho- 
logical changes. So far as our present knowledge goes, other organ- 
isms, such as the bacillus coli, the gonococcus, or Loffler's bacillus, are 
also capable of giving rise to puerperal septic diseases which we cannot 
clinically distinguish, except by culture, from the septicaemia produced 
by streptococci. It may be taken as certain that streptococci bear an 
intimate and important relation to the disease; but whether they 
themselves form the septic matter or carry it, or whether they are 
mere accidental concomitants of the pyaemic processes, it is impossible, 
in the present state of our knowledge, to decide. 

Channels of Diffusion. — Passing on to the channels of diffusion 
through which the septic matter may act, we have to consider its effects 
on the structures with which it is brought into contact, and the mode 
in which it may infect the system at large ; and this will include a 
consideration of the pathological phenomena. 

Local changes consequent on the absorption of the poison are 
pretty constant, and of these we may form an intelligent idea by 
thinking of them as similar in character and causation to those which 
we have the opportunity of studying when septic matter is applied to 
a wound open to observation, as, for example, in cases of blood- 
poisoning following a dissection wound. Distinct traces of local action 
are not of invariable occurrence, and in some of the worst class of 
cases, when the amount of septic matter is great and its absorption 
rapid, death may occur after an illness of short duration but great 
intensity, and before appreciable local changes, either at the site of 
absorption or in the system at large, have had time to develop them- 
selves. The fact that puerperal fever may prove fatal, Avithout leaving 
any tangible post-mortem signs, has often been pointed out, such cases 
most frequently occurring during the endemic prevalence of the disease 
in lying-in hospitals. There can be little doubt, however, that in such 
cases of intense septicaemia marked pathological changes .exist in the 
form of alterations of the blood and degenerations of tissue, but not 
of a character which can be detected by an ordinary post-mortem 
examination. In the great majority of cases, indications of the disease 
exist at the site of absorption. These are described by pathologists as 
identical in their character with the inflammatory oedema which occurs 
in connection with phlegmonous erysipelas. If lacerations exist in 
the cervix or vagina, they take on unhealthy action, their edges 
swell, and their surfaces become covered with a yellowish coat, similar 
in appearance to diphtheritic membrane. The mucous membrane of 
the uterus is also generally found to be affected, and in a degree vary- 
ing with the intensity of the local septic process. There is evidence 
of severe endometritis ; and. very frequently, the whole lining of the 
uterus is profoundly altered, softened, covered with patches of diph- 
theritic deposit, anrl it may be in a state of general necrosis (Plate 
VII., Fig. 2). In the severer cases these changes affect the muscular 



624 THE PUERPERAL STATE. 

tissue of the uterus, which is found to be swollen, soft, imperfectly 
contracted, and even partially necrosed, a condition which is likened 
by Heiberg to hospital gangrene. The connective tissue surrounding 
the generative tract is also swollen and cedematous, and the inflamma- 
tion may in this way reach the peritoneum, although peritonitis, so 
often observed in puerperal septicaemia, does not necessarily depend on 
the direct transmission of inflammation from the pelvic connective 
tissue, but is more often a secondary phenomenon. 

The channels through which general systemic infection may 
supervene are the lymphatics and the venous sinuses, the former 
being by far the most important. Recent researches have shown the 
great number and complexity of the lymphatics in connection with the 
pelvic viscera, and marked traces of the absorption of septic matter 
are almost always to be found, except in those very intense cases 
already alluded to, in which no appreciable post-mortem signs are dis- 
coverable. The septic matter is probably absorbed from the lymph spaces 
abounding in the connective tissue, and carried along the lymphatic 
canals to the nearest glands. The result is inflammation of their coats, 
and thrombosis of their contents, which may be seen on section as a 
creamy; purulent substance. The absorptiou of septic material may 
be delayed by the local changes produced in the lymphatics and in the 
glands with which they communicate, which are, therefore, conserva- 
tive in their action; and the further progress of the case may in this 
way be stopped and local inflammation aloue result, such cases being 
believed by Heiberg to be examples of abortive pyaemia. On the other 
hand, the free septic material may be too abundant and intense to be 
so arrested, it may pass on through the lymph canals and glands, until 
it reaches the blood-current through the thoracic duct, and so produces 
a general blood-infection. This mode of absorption of septic matter, 
and the tendency of the glands to arrest its further progress, serve to 
explain the progressive character of many cases, in which fresh exacer- 
bations seem to occur from time to time ; since fresh quantities of 
poison, generated at its source of origin, may be absorbed as the case 
progresses. The uterine veins are supposed to be the chaunel of 
absorption in the intense form of disease which proves fatal very shortly 
after delivery, too soon for the more gradual process of lymphatic 
absorption to have become established. It is evident that the veins 
are not likely to act in this way, since they must, under ordinary cir- 
cumstances, be completely occluded by thrombi, otherwise hemorrhage 
would occur. If, however, uterine contraction be incomplete, the 
occlusion of the venous sinuses may be imperfect, and absorption of 
septic material through them may then take place. Some writers have 
laid great stress on imperfect uterine contraction in predisposing to 
septicaemia, and its influence may thus be well explained. The veins 
may bear an important part in the production of septicaemia, inde- 
pendent of the direct absorption of septic matter through them, by 
means of the detachment of minute portions of their occluding thrombi, 
in the form of emboli. If phlegmonous inflammation occurs in the 
immediate vicinity of the veins, the thrombi they contain may become 
infected. When once blood-infection has occurred by any of these 
channels, general septicaemia, the co-called puerperal fever, is developed. 



PUERPERAL SEPTIC DISEASE, 625 

Pour Principal Types of Pathological Change. — The variety of 
pathological phenomena found on post-mortem examination has had 
much to do with the prevalent confusion as to the nature of the disease. 
This has resulted in the description of many distinct forms of puerperal 
fever, the most marked pathological alteration having been taken to 
be the essential element of the diseasee. As a matter of fact, there is 
no doubt that various types of pathological change are met with. 
Heiberg describes four chief classes which are by no means distinctly 
separated from one another, are often found simultaneously in the 
same subject, and are certainly not to be distinguished by the symp- 
toms during life. 

Of these the first is the class of cases in which no appreciable morbid 
phenomena are fouud after death. This formidable and fatal form of 
the disease has long been well known, and is that described by some 
authors as adynamic or malignant puerperal fever. It is the variety 
which was so prevalent in our lying-in hospitals, and which Ramsbotham 
talks of as being second only to cholera in the severity and suddenness 
of its onset and in the rapidity with which it carried off its victims. 
It is quite erroneous to suppose that the existence of pathological 
changes in this form of disease has never been recognized. Even with 
the coarse methods of examination formerly used, the occurrence of a 
fluid and altered state of the blood, and ecchymoses in connection with 
various organs — especially the lungs, spleen, and kidneys — were noticed 
and specially described by Copland in his Dictionary of Medicine. We 
now know that there exist, in addition, the commencement of inflam- 
mation in most of the tissues, shown by cloudy swellings, and granular 
infiltration and disintegration of the cell elements; proving that the 
blood, heavily charged with septic matter, had set up morbid action 
wherever it circulated, the patient succumbing before this had time to 
develop. 

In the second type, and that perhaps most commonly met with, the 
morbid changes are more frequently found in the serous membranes, 
in the pleura, in the pericardium, but, above all, in the peritoneum, the 
alterations in which have long attracted notice and have been taken 
by many writers as proving peritonitis to be the main element of the 
disease. Evidences of more or less peritonitis are very general. In 
the more severe cases there is little or no exudation of plastic lymph, 
such as is found in peritonitis unassociated with septicemia. There 
is a greater or less quantity of brownish serum only, the coils of in- 
testine, distended with flatus and highly congested, being surrounded 
bv it. More often there are patchy deposits of fibrinous exudation 
over many of the viscera, the fundus uteri, the under surface of the 
liver, and the distended intestines. There is then, also, a considerable 
quantitv of sero-purulent fluid in the abdominal cavity. The pleural 
cavities may also exhibit similar traces of inflammatory action, con- 
taining imperfectly organized lymph and sero-purulent fluid. Schroeder 
states that pleurisy is more often the direct result of transmission of 
inflammation through the substance of the diaphragm or lung than a 
seconclarv consequence of the septicemia. In like manner evidences 
of pericarditis mav exist, the surface of the pericardium being highly 

40 



626 



THE PUERPERAL STATE. 



injected and its cavity containing serous fluid. Inflammation of the 
synovial membranes of the larger jointSj occasionally ending in sup- 
puration, is not uncommon and may probably be best included under 
this class of cases. 

In the third type the mucous membranes appear to bear the brunt 
of the disease. The pathological changes are most marked in the 
mucous membrane lining the intestines, which is highly congested and 
even ulcerated in patches, with numerous small spots of blood ex- 
travasated in the submucous tissue. Similar small apoplectic effusions 
have been observed in the substance of the kidneys and under the 
mucous membrane of the bladder. Pneumonia is of common occur- 
rence. In most cases it is probably secondary to the impaction of 



Fig. 198. 



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DAY OF 

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A. S., aged thirty years; confined February 27, 1879; died March 10th. 

minute emboli in the smaller branches of the pulmonary artery ; but 
it may doubtless arise from independent inflammation of the lung 
tissue, and will then be included in a class of cases now under con- 
sideration. 

The fourth class of pathological phenomena are those which are 
produced chiefly by the impaction of minute infected emboli in small 
vessels in various parts of the body. These are the cases which most 
closely resemble surgical pyaemia, both in their symptoms and post- 
mortem signs, and which by many writers are described under the 



PUERPERAL SEPTIC DISEASE. 



627 



name of puerperal pyaemia. The dependence of puerperal fever on 
phlebitis of the uterine veins Avas a favorite theory, and in a large 
proportion of eases the coats of the veins show signs of inflammation, 
their canals being occupied with thrombi in a more or less advanced 
state of disintegration. The mode in which these thrombi may become 
infected has been shown by Babnoff, who has proved that bacteria 
may penetrate the coats of the vein, and entering its contained coagulum 
may set up disintegration and suppuration. This observation brings 
these pyemic forms of disease into close relation with septicemia such 
as we have been studying, and justifies the conclusion of Verneuil 
that purulent infection is not a distinct disease, but only a termination 

Fig. iya. 



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Mrs. D., aged twenty-five years; confined May 1, 1S79. Puerperal septicaemia; recovery. An 
untrapped pipe, communicating with sewer, was found in bath close to this patient's bed. 

of septicemia, with which it ought to be studied. We have, more- 
over, to differentiate these results of embolism from those considered 
in a subsequent chapter, the characteristic of these cases being the 
infected nature of the minute emboli. Localized inflammations and 
abscesses, from the impaction of minute capillary emboli, are found in 
many parts of the body; most frequently in the lungs, then in the 
kidneys, spleen, and liver, and also in the muscles and connective 
tissues. Pathologists are by no means agreed as to the invariable 
dependence of these on embolism, nor is it possible to prove their 



628 



THE PUERPERAL STATE, 



origin from this source by post-mortem examination. Some attribute 
all such cases to embolism, others think that they may be the results 
of primary septicsemic inflammation. It has been proved by Weber 
that minute infected emboli may pass through the lung capillaries ; 
and this disposes of one argument against the embolic theory, based 
on the supposed impossibility of their passage. It is probable that 
both causes may operate, and that localized inflammations occurring a 
short time after delivery are directly produced by the infected blood, 
while those occurring after the lapse of some time, as in the second or 
third week, depend upon embolism. 

Description of the Disease. — From what has been said as to the 
mode of infection in puerperal septicaemia, and as to the very various 
pathological changes which accompany it, it will not be a matter of 
surprise to find that the symptoms are also very various in different 
cases. This can readily be explained by the amount and virulence of 

the poison absorbed, the channels of 
infection, and the organs which are 
chiefly implicated ; but it renders it 
very difficult to describe the disease 
satisfactorily. 

The symptoms generally show 
themselves within two or three days 
after delivery. As infection most 
often occurs during labor, or in cases 
which are saprsemic within a short 
time afterward, and before the lesions 
of continuity in the generative tract 
have commenced to cicatrize, it can 
be understood why septicaemia rarely 
commences later than the fourth or 
fifth day. 

In the great majority of cases the 
disease begins insidiously. There 
are, generally, some chilliness and 
rigor, but by no means always, and 
even when present they frequently 
escape observation or are referred to 
some transient cause. The first symp- 
tom which excites attention is a rise 
in the pulse, which may vary from 
100 to 140 or more, according to the 
severity of the attack ; and the ther- 
mometer will also show that the tem- 
perature is raised to 102°, or, in bad 
cases, even to 104° or 106°. Still it 
must be borne in mind that both the 
pulse and temperature may be in- 
creased in the puerperal state from transient causes, and do not of 
themselves justify the diagnosis of septicaemia. 

In the more intense class of cases, in which the whole system seems 











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28 



Mrs. P., aged twenty- four years; labor 
natural ; confined May 22, 1880. A piece of 
decomposed membrane the size of hand 
washed out of her uterus at first intra-uterine 
injection; rapid recovery. 



PUERPERAL SEPTIC DISEASE. 



629 



overwhelmed with the severity of the attack, the disease progresses 
with great rapidity, and often without any appreciable indication of 
local complication. The pulse is very rapid, small, and feeble, varying 
from 120 to 140, and there is generally a temperature of 103° to 104°. 
In the worst form of cases the temperature is steadilv high without 
marked remissions (see Figs. 1 98, 203, and 204). There may be little 
or no pain, or there may be slight tenderness on pressure over the 
abdomen or uterus ; and, as the disease progresses, the intestines get 
largely distended with flatus, so that intense tympanites often forms a 
most distressing symptom. The countenance is sallow, sunken, and 



Fig. 201. 



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NORM. TEM 
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PULSE 








84 


96 


84 


116 


96 


120 


88 


78 








DATE 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 



Mrs. KT., aged twenty-two years ; cor.fined Thursday, May 6, 18*0. Forceps, 
offensive ; a small piece of membrane was probably left in utero. 



.ochia from the first 



has a very anxious expression. As a rule, intelligence is unimpaired, 
and this may be the case even in the worst forms of the disease, and 
up to the period of death. At other times there is a good deal of low 
muttering delirium, which often occurs at night alone, and alternates 
with intervals of complete consciousness, but is occasionally intensified 
for a short time into a more acute form. Diarrhoea and vomiting are of 
very frequent occurrence ; by the latter, dark, grumou«, coffee-ground 
substauces are ejected. The diarrhoea is occasionally very profuse and 
uncontrollable ; in mild cases it seems to relieve the severity of the 
symptoms. The tongue is rnoi-t and loaded with sordes ; but some- 



630 



THE PUERPERAL STATE 



times it gets dark and dry, especially toward the termination of the 
disease. The lochia are generally suppressed or altered in character, 
and sometimes they have a highly offensive odor, especially when the 
disease is of the saprsemic type. The breathing is hurried and panting, 
and the breath itself has a very characteristic, heavy, sweetish odor. 
The secretion of milk is often, but not always, arrested. 

Duration. — With more or less of these symptoms the case goes on ; 
and when it ends fatally it generally does so within a week, the fatal 
termination being indicated by more weakness, rapid, thread-like, or 
intermittent pulse, marked delirium, great tympanites, and sometimes 



Fig. 202. 



TIME 


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DAY OF 
DIS. 








1ST. 


2ND. 


3RD. 


4TH. 


5TH. 


6TH. 


7TH. 


8TH. 


9TH- 


10TH 


11th 


12TH. 


13TH 


14TH 


15TH 


J6TH. 


17th. 




PULSE 


"\7S 


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^130 
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DATE 


26 


27 


28 


29 


30 


31 


Augl 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 



Mrs. 



aged twenty-five years ; recovery. Confined July 26, 1879, 7.40 p.m. 



a sudden fall of temperature, until at last the patient sinks with all the 
symptoms of profound exhaustion. 

In milder cases similar symptoms, variously modified and combined, 
are present. It is seldom that two precisely similar cases are met with; 
in some the rapid, weak pulse is most marked; in others abdominal 
distention, vomiting, diarrhoea, or delirium. 

Local complications variously modify the symptoms and course of 
the disease. The most common is peritonitis, so much so that with 
some authors puerperal fever and puerperal peritonitis are synonymous 
terms. Here the first svmotom is severe abdominal pain, commencing 



PUERPERAL SEPTIC DISEASE. 



631 



at the lower part of the abdomen, where the uterus is felt enlarged and 
tender. As the abdominal pain and tenderness spread, the sufferings of 
the patient greatly increase, the intestines become enormously distended 
with flatus, and the breathing is entirely thoracic, in consequence of 
the upward displacement of the diaphragm and the fact that the 
abdominal muscles are instinctively kept as much in repose as possible. 
The patient lies on her back with her knees drawn up and sometimes 
cannot bear the slightest pressure of the bedclothes. There is gener- 
ally much vomiting, and often severe diarrhoea. The temperature 
generally ranges from 102° to 104°, or even 106°, and is subject to 

Fig. 203. 



TIME 


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DAY OF 
DIS. 


1st. 


2nd. 


3RD. 


4th. 


5TH. 


6TH. 


7th. 


8TH. 


9TH. 


10TH. 


11th. 


12TH. 


13TH. 


14TH. 


15TH. 


16th. 


17TH. 


18TH. 


19th 


20TM. 


PULSE 




130 








120 




150 








100 


















DATE 


Aug6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 



Mrs. M. K., aged twenty-one years ; infection believed to be due to scarlatina. 
Confined August 5, 1878 ; recovery. 

occasional exacerbations and remissions, possibly depending on fresh 
absorption of septic matter (see Figs. 199, 201, and 202). The case 
generally lasts for a week or more, the symptoms going on from bad 
to worse, and the patient dying exhausted. D'Espine points out that 
rigors, with exacerbations of the general symptoms, not unfrequently 
occur about the sixth or seventh day, which he attributes to fresh 
systemic infection from fetid pus in the peritoneal cavity. It must 
not be supposed that all these symptoms are necessarily present when 
the peritonitic complication exists. Pain is especially often entirely 
absent, and I have seen cases in which post-mortem examination 
proved the existence of peritonitis in a very marked degree, in which 



632 THE PUERPERAL STATE, 

pain was entirely absent. Sometimes the pain is only slight and 
amounts to little more than tenderness over the uterus. 

Symptoms of other local complications are characterized by their 
own special symptoms: thus, pneumonia by dyspnoea, cough, dulness, 
etc. ; pericarditis by the characteristic rub ; pleurisy by dulness on per- 
cussion ; kidney affection by albuminuria and the presence of casts ; 
liver complication by jaundice; and so on. 

Pyeemic Forms of the Disease. — The course of the disease is not 
always so intense and rapid, being in some cases of a more chronic 
character and lasting many weeks. The symptoms in the early stage 
are often indistinguishable from those already described, and it is 
generally only after the second week that indications of purulent infec- 
tion develop themselves. Then we often have recurrent and very 
severe rigors, with marked elevations and remissions of temperature. 
At the same time there is generally an exacerbation of the general 
symptoms, peculiar yellowish discoloration of the skin, and occasionally 
well-developed jaundice. Transient patches of erythema are not un- 
commonly observed on various parts of the skin, and such eruptions 
have often been mistaken for those of scarlet fever or other zymotic 
disease. Localized inflammations and suppuration may rapidly follow. 
Amongst the most common are inflammation or even suppuration of 
the joints — the knees, shoulders, or hips — which is preceded by diffi- 
culty of movement, swelling, and very acute pain. Large collections 
of pus in various parts of the muscles and connective tissues are not 
rare. Suppurative inflammation may also be found in connection 
with many organs, as in the eye, in the pleura, pericardium, or lungs ; 
each of which will, of course, give rise to characteristic symptoms, 
more or less modified by the type of the disease and the intensity of 
the inflammation. 

Puerperal Malarial Fever. — There is a peculiar form of febrile 
disturbance which sometimes occurs in the puerperal state, and which 
is apt to be confounded with septicaemia, to which attention was 
specially directed by the late Fordyce Barker, 1 under the name of 
" puerperal malarial fever." It is specially apt to be met with in 
women who have been exposed to malarial poison duriug their former 
lives, the recurrence of the fever being probably determined by the 
puerperal state. Of this I have seen several very well-marked ex- 
amples in ladies who had formerly contracted fever and ague in India. 
One of my patients who has been long in India, and suffered from 
intermittent fever for years, is invariably attacked with it after 
delivery, and herself warned me of the fact the first time I attended 
her. The diagnosis is not always easy. Barker insisted on the fact 
that puerperal malarial fever generally commences after the fifth day 
of delivery, while septicaemia almost always does so before that time. 
In the malarial fever, moreover, the intermissions are much more 
marked, while there are frequently recurring chills or rigors, which is 
not the case in septicaemia. 

Treatment. — In considering the all-important subject of treatment, . 

1 "Puerperal Malarial Fever," Amer. Journ. of Obstet.. vol. xiii. p. 271. 



PUERPERAL SEPTIC DISEASE. 633 

the views of the practitioner are naturally biased by the theory he has 
adopted of the nature of the disease. If that here inculcated be cor- 
rect, the indications we have to bear in mind are : first, to discover, if 
possible, the source of the poison, in the hope of arresting further septic 
absorption ; secondly, to keep the patient alive until the effects of the 
poison are worn off; and thirdly, to treat any local complication that 
may arise. 

The first is likely to be of great importance in cases of saprsemia, as 
fresh quantities of septic matter may be from time to time absorbed. 
We, fortunately, are in possession of a powerful means of preventing 
further absorption by the application of antiseptics to the interior of 
the uterus and to the canal of the vagina. This is especially valuable 
when the existence of decomposing coagula or other sources of septic 
matter is suspected in the uterine cavity, or when offensive discharges 
are present. Disinfection is readily accomplished by washing out the 
uterine cavity, at least twice daily, by means of a Higginson syringe 
with a long vaginal pipe attached. 1 The results are sometimes very 
remarkable, the threatening symptoms rapidly disappearing and the 
temperature and pulse falling so soon after the use of the antiseptic 
injections as to leave no doubt of the beneficial effects of the treatment. 
I cannot better illustrate the advantages of this treatment than by the 
temperature chart (Fig. 206), which is from a case which came under 
my observation in the outdoor practice of King's College Hospital. 
It was that of a healthy woman, thirty-six years of age, who had an 
easy and natural labor. Nothing remarkable was observed until 
the third day after delivery, when the temperature was found to be 
slightly increased. On the morning of the eighth day the temperature 
had risen to 105.8°. She was delirious, with a rapid, thready pulse, 
clammy perspiration, tympanitic abdomen, and her general condition 
indicated the most urgent danger. On vaginal examination a piece of 
compressed and putrid placenta was found in the os. This was 
removed by my colleague, Dr. Hayes, and the uterus thoroughly 
washed out with Condy's fluid and water. The same evening the 
temperature had sunk to 99° and the general symptoms were much 
improved. The next day there was a slight return of offensive dis- 
charge, and an aggravation of the symptoms. After again washing 

1 My colleague, Dr. Hayes, has invented a silver tube for the purpose of administering' such intra- 
uterine injections (Fig. 204), which answers its purpose admirably. The numerous apertures at its 

Fig. 204. 




Hayes's tube for intra-uterine injections. 

extremity allow of a number of minute streams of fluid being thrown out in the form of a spray 
over the interior of the uterus, the complete bathing of its surface and washing out of its cavity 
being thus insured. It is. moreover, introduced more easily than the ordinary vaginal pipe, and 
can be attached to a Higginson syringe. 



634 



THE PUERPERAL STATE, 



out the uterus the temperature fell, aud from that date the patient con- 
valesced without a single bad symptom. 

This is a very well marked example of the value of local antiseptic 
treatment, and I have seen many cases of the same kind. It should, 
therefore, never be omitted in all cases in which the presence of deconi- 



Fig 205. 



TIME 


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DAY OF 
DIS. 




1ST. 


2ND. 


3RD. 


4TH. 


5TH. 


6th. 


7TH. 


8TH. 


9TH, 


PULSE 




1CH\ 


\^ 


\l26 


\^36 










156"\ 


DATE 


Mr29 


30 


31 


Apr.l 


2 


3 


4 


5 


6 


7 



Mrs. B., aged twenty-nine years ; confined March 29 ; died April 7, 1879. 
Fig. 206. 



107* 
lot* 

105" 
a 
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< 104 

IS 

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X 

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posing structures within the uterus is suspected ; and, indeed, even 
when there is no reason to suspect the presence of a local focus of 
infection, the use of antiseptic lotions is advisable as a matter of pre- 
caution, since it can do no harm and is generally comforting to the 
jmtient. Various antiseptics may be used, such as a weak solution of 



PUERPERAL SEPTIC DISEASE. 635 

carbolic acid, 1 : 50, tincture of iodine dropped into warm water until 
it has a pale sherry color, or a solution of perchloride of mercury of 
the strength of 1 : 2000. Of these, the perchloride of mercury solution 
is the most effective germicide, and Koch's experiments have conclu- 
sively proved that it is the only recognized antiseptic which can be 
relied upon for destroying the spores of micro-organisms after a single 
application. As, however, there is a possibility that a too free and 
incautious use of the corrosive sublimate might prove poisonous, it 
would be well that such intra-uterine injections should not be stronger 
than 1 : 2000, and that they should be practised by the medical man 
himself, the quantity for such irrigation not exceeding two quarts. 1 
One or other of these may be advantageously used alternately — one in 
the morning, the other in the evening. Occasionally I have employed 
a 1 : 50 solution of carbolic acid, with about 5 grains to the ounce of 
iodoform suspended in it. This has the advantage of not only being a 
powerful antiseptic, but of acting more continuously in consequence of 
the powdered iodoform remaining partially attached to the uterine 
walls ; or, as some have advised, an iodoform bougie 2 may be placed 
in the uterine cavity, or powdered iodoform insufflated through the 
cervix. The nozzle of the syringe should be guided well through the 
cervix, and the cavity of the uterus thoroughly washed out until the 
fluid that issues from the vagina is no longer discolored. As the os is 
always patulous, there is no risk of producing the troublesome symp- 
toms of uterine colic, which occasionally follow the use of intra-uterine 
injections in the unimpregnated state. It is quite useless to intrust 
the injection to the nurse, and it should be performed at least twice 
daily by the practitioner himself, in all cases in which the discharges 
are offensive. It is not advisable, however, that such injections should 
be used indiscriminately, since they are not entirely free from risk 
and may even be the means of introducing fresh septic matter into the 
uterine cavity. It has been pointed out 3 that sometimes the intra- 
uterine injection itself produces rigors and other nervous troubles. I 
am certain that this observation is correct, and I have myself more 
than once seen a severe rigor rapidly follow its administration. In 
any case it is useless to continue the use of intra-uterine injections for 
more than one or two days ; they may be serviceable in the earlier 
stages of the disease, but when systemic infection has occurred they 
cease to be of use. The vulva should in all cases be carefully inspected 
with the view of ascertaining if the source of infection be not some 
local slough or necrotic ulcer about the perineum or orifice of the 
vagina, in which case its surface should be freely scraped aud covered 
with iodoform. I have seen more than one instance in which this 
simple procedure has sufficed to cut short symptoms of a very threat- 
ening character. 

Curetting' the Uterine Cavity. — Curetting the interior of the uterus 
has been strongly recommeuded and largely practised. It may obvi- 

1 Herff: " Ueber Ursachen und Verhiitung der Sublimat-Vergiftung," etc., Arch. f. Gyniik ., 
1885. Bd. xxv. S. 487. 

2 These may be made of gum arabic and glycerin, about two and a half inches in length, each 
containing 90 grains of iodoform. 

3 Mangrin : " Quelques accidents provoques par les injections intra-uterines," Nouv. Area. 
d'Obstet. et de Gyn., 1888, p. 38. 



636 THE PUERPERAL STATE. 

ously be valuable in cases in which retention of portions of the placenta 
or membranes is suspected, or in which a highly offensive discharge 
leads us to think that a necrosed condition of the decidua may exist. 
The patient is placed in the semi-prone position, the vagina irrigated 
with a sublimate solution and the anterior lip of the cervix drawn 
down with a volsella, and the endometrium thoroughly scraped with a 
blunt curette. The cavity of the uterus is subsequently well swabbed 
out with tincture of iodine. It can be readily understood that such a 
procedure is more thorough and complete than intra-uterine injection, 
and there can be no objection to a careful use of it in hands tolerably 
expert in obstetric manipulations. It must, however, be only practised 
in exceptional cases, and with great caution, since any roughness might 
seriously injure the uterine structures. It must be borne in mind also 
that it is only in the early stages of the disease that this, like intra- 
uterine douching, is at all likely to be of service. When once the 
septic germs have penetrated the underlying tissues, and produced 
general systemic infection, both are equally useless. 

Administration of Food and Stimulants. — In a disease char- 
acterized by so marked a tendency to prostration, the importance of 
sustaining the vital powers by an abundance of easily assimilated nour- 
ishment cannot be overrated. Strong beef-tea or other forms of animal 
soup, milk, alone or mixed either with lime- or soda-water, and the 
yelk of eggs, beat up with milk and brandy, should be given at short 
intervals and in as large quantities as the patient can be induced to 
take ; and the value of thoroughly efficient nursing will be especially 
apparent in the management of this important part of the treatment. 
As there is frequently a tendency to nausea the patient may resist the 
administration of food, and the resources of the practitioner will be 
taxed in administering it in such form and variety as will prove least 
distasteful. Generally speaking, not more than one or two hours should 
be allowed to elapse without some nutriment being given. The amount 
of stimulant required will vary with the intensity of the symptoms and 
the indications of debility. Generally, stimulants are well borne, prove 
decidedly beneficial, and require to be given pretty freely. In cases 
of moderate severity a tablespoonful of good old brandy or whiskey 
every four hours may suffice ; but when the pulse is very rapid and 
thready, when there is much low delirium, tympanites, or sweating 
(indicating profound exhaustion), it may be advisable to give them in 
much larger quantities and at shorter intervals. The careful practi- 
tioner will closely watch the effects produced, and regulate the amount 
by the state of the patient rather than by any fixed rule ; but in severe 
cases eight or twelve ounces of brandy, or even more, in the twenty-four 
hours may be given with decided benefit. 

Venesection, both general and local, was long considered a sheet- 
anchor in this disease. Modern views are, however, entirely opposed 
to its use ; and in a disease characterized by so profound an alteration 
of the blood and so much prostration, it is too dangerous a remedy to 
employ, although it is possible that it might alleviate temporarily the 
severity of some of the symptoms, especially in cases in which perito- 
nitis is well marked and much local pain and tenderness are present. 



PUERPERAL SEPTIC DISEASE. 



637 



Treatment by Antistreptococcic Serum. — Within the past few 
years the subject of greatest interest in connection with puerperal septic 
disease has been its treatment by the hypodermic injection of antistrep- 
tococcic serum. On this, unfortunately, we are not yet in a position to 
form any reliable opiuion. A large number of cases have been reported 
in which it has been used, generally in a purely empirical way, and in 
combination with other methods of treatment, such as curetting, intra- 
uterine douches, medicines, and the like. In some it has apparently 
had good effects, the temperature has fallen, and the patient has recov- 
ered; but whether this is a " propter hoc " or a " post hoc," it is as 
yet impossible to say. Out of 70 cases in which it was used, collected 
by Eden, 26 died and 44 recovered, showing a mortality, therefore, of 
37.1 per cent, a result which he properly describes as " not very en- 
couraging." The present position on the matter seems to be that this 
treatment is most likely to be useful in cases of streptococcic infection, 
to which it should be limited ; and that for the purpose of ascertaining 
whether the disease is, or is not, of this type, whenever at all feasible 
a bacteriological examination should be made of the discharges from the 
uterus. This is not a difficult matter. It may be efficiently done by 
wrapping a small piece of sterilized cotton round a Playfair's probe, or 
the end of an ordinary knitting-needle, first sterilized by thorough 
heating in the flame of a spirit lamp. Some of the discharge is swabbed 
out of the uterine cavity with this, the cervix having been exposed 
through a speculum. The wooden handle or needle is then shortened 

Fig. 207. 





a b c 

Pure cultivations of streptococcic pyogenes. (After Crookshank.) 
a. On the surface of nutrient gelatin ; b. in the depth of nutrient gelatin ; c. on the surface of 

nutrient agar. 

and placed in a test-tube, well heated or previously boiled, and corked 
up with medicated wool. This can be sent by post to one of the 



638 THE PUERPERAL STATE. 

clinical research associations or bacteriological laboratories attached to 
all our medical schools, and a report could be had by telegraph in the 
course of forty-eight hours in any part of the United Kingdom. No 
doubt facilities for accurate investigations of this kind will be more 
readily accessible to us from day to day. This is the very simple plan 
recommended to me by my colleague, Professor Crookshank, as thor- 
oughly efficient, and the advantage of which I have myself tested. 
The accompanying woodcut (Fig. 207) represents the result of such an 
examination. Failing this better method, an ordinary cover-glass 
preparation may be sufficient to demonstrate the existence of numerous 
streptococci. Fortified by such corroborative evidence, we should have 
no hesitation in advising the use of the serum treatment, with some 
degree of confidence that we are not using it in a haphazard way. If 
the report showed the absence of streptococci, or, as in Haultain's case, 
the presence of diphtheritic infection, then we would either trust to 
ordinary treatment, or, in the latter case, use the diphtheritic antitoxin, 
as he did with the most satisfactory results. The fact is, however, that 
the whole subject of serum therapeutics is as yet in the most elementary 
state. We may look forward with hope to future satisfactory results, 
and scientific rules for our guidance, but at present such knowledge does 
not exist. We do not even know how the remedy acts, or if it acts at 
all. We are therefore certainly not entitled to trust to this treatment 
alone, or justified in neglecting the other means at our disposal of deal- 
ing with the septic infection. When, either on bacteriological or clinical 
grounds, we determine to use the antistreptococcic serum it seems best 
to commence the treatment with a fairly large initial dose, such as 20 
cm., continuing subsequent injections of 10 cm. or less at intervals of 
twelve to twenty-four hours. Three to four injections in all are about 
the average that have been given, and should be quite enough to test 
the efficiency of the treatmeut. If a markedly good effect has not fol- 
lowed, the injections should be discontinued. 

Medicinal Treatment. — The rational indications in medical treat- 
ment are to lessen the force of the circulation as much as is possible 
without favoring exhaustion, and to diminish the temperature. 

For the former purpose Barker strongly advocated the use of vera- 
trum viride, in doses of five drops of the tincture every hour, until the 
pulse falls to below 100, when its effects are subsequently kept up by two 
or three drops every second hour. Of this drug I have no personal ex- 
perience ; but I have extensively used minute doses of tincture of aconite 
for the same purpose, and, when carefully given, I believe it to be a 
most valuable remedy. The way I have administered it is to give a 
single drop of the tincture, at first every half-hour, increasing the 
interval of administration according to the effect produced. Generally, 
after giving four or five doses at intervals of half an hour, the pulse 
begins to fall, and afterward a few doses at intervals of one or two 
hours will suffice to prevent the heart's action rising to its former 
rapidity. The advantage of thus modifying the cardiac action, with 
the view of preventing excessive Avaste of tissue, cannot be questioned. 
It is evident that so powerful a remedy must not be used without the 
most careful supervision, for, if continued too long, or given at too 



PUERPERAL SEPTIC DISEASE. 639 

frequent intervals, it may unduly depress the circulation and do more 
harm than good. It is necessary, therefore, that the practitioner 
should constantly watch the effect of the drug, and stop it if the pulse 
become very weak, or if it intermit. It is most likely to be useful at 
an early stage of the disease before much exhaustion is present, and 
then only when the pulse is of a certain force and volume. Barker 
says of the veratrum viride, what is also true of aconite, that " it 
should not be given in those cases in which rapid prostration is man- 
ifested by a feeble, thread-like, irregular pulse, profuse sweats, and 
cold extremities." 

The Reduction of Temperature must form an important part of 
our treatment, and for this purpose many agents are at our disposal. 

Quinine in large doses, of from 10 to 30 grains, has been much 
used for this purpose. After its exhibition the temperature frequently 
falls one or two degrees. It may be given morning and evening. 
Unpleasant head-symptoms, deafness, and ringing in the ears often 
render its continuance for a length of time impossible. These may, 
however, be much lessened by the addition of 10 to 15 minims of 
hydrobromic acid to each dose. 

Antipj rine in doses of 20 grains every three or four hours some- 
times proves very efficacious ; but, as it is apt to depress, it should be 
combined with some stimulant, such as 30 minims of sal-volatile. 

Salicylic acid, in doses of from 10 to 20 grains, or the salicylate of 
soda in the same doses, is a valuable antipyretic which I have found 
on the whole more manageable than quinine. Under its use the 
temperature often falls considerably in a short space of time. It is, 
however, apt to depress the circulation, and thus requires to be care- 
fully watched while it is being administered ; and should the pulse 
become very small and feeble, it should be discontinued. 

In some cases, especially when the fever has assumed a remittent 
type, I have administered with marked benefit a drug which is of 
high repute in India in the worst class of malarious remittent fevers, 
and the almost marvellous effects of which in such cases I had myself 
witnessed in India many years ago. This is the so-called Warburg's 
tincture, the value of which has been testified to by many high authori- 
ties, among whom I may mention Dr. Maclean, of Netley, Dr. Broad- 
bent, and Sir Alexander Armstrong, the Director-General of the 
Medical Department of the Xavy, who informs me that it is now sup- 
plied to all Her Majesty's ships in the tropics, because it is found to 
be of the utmost value in cases in which quinine has little or no effect. 
Recently its composition has been made public by Dr. Maclean. The 
basis is quinine, in combination with various aromatics and bitters, 
some of which probably intensify its action. Be this as it may, the testi- 
mony in favor of the antipyretic action of the remedy is very strong. 
I have found its exhibition followed by a profuse diaphoresis (this 
being its almost invariable effect), and sometimes a rapid amelioration 
of the symptoms. In other cases in which I have tried it, like every- 
thing else, it has proved of no avail. Of its use in the malarial cases 
above alluded to, Dr. Fordyce Barker says : " For nearly two years 
past, in those cases where the stomach will tolerate it, I have found 



640 THE PUERPERAL STATE. 

Warburg's tincture much more effective and speedy in producing the 
results desired than the largest doses of quinine." 

Application of Cold. — Cold may be advantageously tried in suit- 
able cases. The simplest mode of using it is by Thornton's ice-cap, 
by which a current of cold water is kept continuously running round 
the head. This has been found of great value in pyrexia after ovari- 
otomy, and I have also found it useful as a means of reducing tempera- 
ture in puerperal cases. It is a comforting application and gives great 
relief to the throbbing headache, which often causes much suffering. 
Under its use the temperature often falls two or more degrees, and it 
is easily continued day and night. 

In very serious cases, when the temperature reaches 105° or upward, 
the external application of cold to the rest of the body may be tried. 
I have elsewhere related 1 a case of puerperal septicaemia with hyper- 
pyrexia, the temperature continuously ranging over 105°, in which I 
kept the patient for eleven days nearly constantly covered with cloths 
soaked in iced water, by which means only was the temperature kept 
within moderate bounds and life preserved. But this method of treat- 
ment is excessively troublesome, and is in no way curative. It is 
only of use in moderating the temperature when it has reached a point 
at which it could not continue long without destroying the patient. 
I should, therefore, never think of employing it unless the temperature 
was over 105°, and then only as a temporary expedient, requiring 
incessant watching, to be desisted from as soon as the temperature had 
reached a more moderate height. It is clearly impossible to place a 
puerperal patient in a bath, as is practised in hyperpyrexia associated 
with acute rheumatism or typhoid fever. The same effect may, how- 
ever, be obtained by placing her on mackintosh sheeting, or still better 
on a water-bed, into which cold water is run from time to time by tubes 
placed at opposite corners, and covering the body with towels soaked in 
ice-water, which are frequently renewed by the attendant nurses. 
During the application the temperature should be constantly taken, 
and as soon as it has fallen to 101° the cold application should be 
discontinued. 

Administration of Turpentine. — Amongst olher remedies which 
have been used is turpentine, which was highly thought of by the 
Dublin school. In cases with much tympanitic distention, and a small 
weak pulse, it is sometimes of unquestionable value, and it probably 
acts as a strong nervine stimulant. Given in doses of 15 to 20 minims 
rubbed up with mucilage, it can generally be taken in spite of its 
nauseous taste. 

Evacuant Remedies. — Purgatives, diaphoretics, or even emetics, 
have often been employed as eliminants of the poison. The former 
are strongly recommended by Schroeder and other German authorities, 
and in England they were formerly amongst the most favorite 
remedies, and there is a general concurrence of opinion amongst our 
older writers as to their value. In the first volume of the Obstetrical 
Journal there is a paper by Mr. Morton, in which this practice is 

1 "A Lecture on a Case of Puerperal Septicaemia with Hyperpyrexia, treated by the Continuous 
Application of Cold," Brit. Med. Journ., vol. ii. p. 687. 



PUERPERAL SEPTIC DISEASE. 641 

strongly advocated, and some interesting cases are recorded in which 
it apparently acted well. He administers calomel in doses of 3 or 4 
grains with compound extract of colocynth, so as to keep up a free 
action of the bowels. It seems quite reasonable, when there is con- 
stipation, to promote a gentle action of the bowels by some mild 
aperient ; but, bearing in mind that severe and exhausting diarrhoea is 
a common accompaniment of the disease, I should myself hesitate to 
run the risk of inducing it artificially, especially as there is no proof 
whatever that septic matter can really be eliminated in this way. At 
the commencement of the disease, however, I have often given one or 
two aperient doses of calomel with decided benefit. 

Internal Antiseptic Remedies. — It is possible that further research 
will give us some means of counteracting the septic state of the blood ; 
and the sulphites and carbolates have been given for this purpose, but 
as yet with no reliable results. 

The tincture of the perchloride of iron naturally suggests itself, 
from its AA'ell-known effects in surgical pyaemia. In the less intense 
forms of the disease, especially when local suppurations exist, it is 
certainly useful, and may be given in doses of 10 to 20 minims every 
three or four hours. In very acute cases other remedies are more 
reliable, aud the iron has the disadvantage of not unfrequently causing 
nausea or vomiting. 

AVhen restlessness, irritation, and want of sleep are prominent 
symptoms, sedatives may be required. Under such circumstances 
opiates may be given at night, and Battley's solution, nepenthe, or the 
hypodermic injection of morphia is the form which answers best. 

Treatment of Local Complications. — Pain, tenderness, and local 
complications must be treated on general principles. The distress 
from them is most experienced when peritonitis is well marked. Then, 
warm and moist applications, in the form of poultices or fomentations, 
are very useful. Relief is also sometimes obtained from turpentine 
stupes, aud when the tympanites is distressing, turpentine enemata are 
very serviceable. I have found the free application over the abdomen 
of the flexible collodium of the Pharmacopceia decidedly useful in alle- 
viating the suffering from peritonitis. 

Laparotomy in cases of puerperal peritonitis has been discussed and 
practised within the last few years. 1 The subject is too new, and, as 
yet, experience far too small, to justify any dogmatic opinion as to its 
merits or demerits. So far as existing evidence seems to show, the 
successful cases have been examples of localized pus deposits, more in 
the nature of pelvic peritonitis, or, in a few cases, of general sup- 
purative peritonitis. In the latter class the operation has been per- 
formed a considerable time after delivery, such as six weeks, but cases 
of this kind cannot with propriety be called true puerperal septicaemia. 
The few cases reported in which laparotomy has been performed soon 
after the development of septic symptoms appear all to have ended 
fatally. This is exactly what one would have & priori expected. In 

1 See Maury, "The Indications for Laparotomy in Puerperal Fever." and Hir^t. "The Position of 
Abdominal Section in the Treatment of Septic Peritonitis after Childbirth," Trans, of the Amer. 
Gyn. Soc, 1S91. 

41 



642 THE PUERPERAL STATE. 

acute septic infection, which is a general and not a local disease, there 
are, it is true, very often marked symptoms of peritoneal disease, such 
as tenderness, immense distention, and the like ; but this is one only of 
many local phenomena. To open the abdomen in such cases would be 
rash in the extreme, and a most hopeless procedure ; it might even be 
impossible to return the enormously inflated intestines. It has been 
said that laparotomy to be of use in cases of this kind must be done 
early, but it is to be remembered that in the early stages of septicaemia 
the symptoms are not well marked. The hope of cutting them short 
has not been abandoned, and it would lead to deplorable results if 
advice of this kind should lead to opening the abdomen of puerperal 
patients as soon as suspicious symptoms arose. In the former class, 
however, it is certain that in well-selected cases laparotomy, washing 
out of the abscess cavity or peritoneum, and drainage, offer by far the 
best prospects of recovery. 

Such are the remedies most used in this disease. It is needless to 
say that it is quite impossible to lay down fixed rules for the manage- 
ment of any individual case ; and it is obvious that, if puerperal septi- 
caemia be not a special and distinct disease, its judicious treatment must 
depend on the general knowledge of the attendant and on a careful 
study of the symptoms each separate case presents. 



CHAPTEE VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis and its Results. — Under the head of 
thrombosis we may class several important diseases connected with the 
puerperal state, which have received far less attention than they deserve. 
It is only of late years that some, we may probably safely say the 
majority, of those terribly sudden deaths which from time to time occur 
after delivery have been traced to their true cause, viz., obstruction of 
the right side of the heart and pulmonary arteries from a blood-clot, 
either carried from a distance or, as I shall hope to show, formed in 
situ. Although the result and, to a great extent, the symptoms, are 
identical in both, still a careful consideration of the history of these 
two classes of cases tends to show that in their production they are 
distinct, and that they ought not to be confounded. In the former we 
have primarily a clotting of blood in some part of the peripheral 
venous system, and the separation of a portion of such a thrombus 
due to changes undergone during retrograde metamorphosis tending to 
its eventual absorption. In the latter we have a local depositing of 
fibrin, the result of blood changes consequent on pregnancy and the 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 643 

puerperal state. The formation of such a coagulum in vessels the 
complete obstruction of which is incompatible with life, explains the 
fatal results. When, however, a coagulum chances to be formed in 
more distant parts of the circulation, the vital functions are not imme- 
diately interfered with, and we have other phenomena occurring, due 
10 the obstruction. The disease known as phlegmasia dolens, I shall 
presently attempt to show, is one result of blood-clot forming in periph- 
eral vessels. But from the evident and tangible symptoms it pro- 
duces, it has long been considered an essential and special disease, and 
the general blood dyscrasia which produces it, as well as other allied 
states, has not been studied separately. I shall hope to show that all 
these various conditions, dissimilar as they at first sight appear, are 
very closely connected, and that they are in fact due to a common 
cause ; and thus, I think, we shall arrive at a clearer and more correct 
idea of their true nature than if we looked upon them as distinct and 
separate affections, as has been commonly done. I am aware that in 
phlegmasia dolens, the pathology of which has received perhaps more 
study than that of almost any other puerperal affection, something 
beyond simple obstruction of the venous system of the affected limb is 
probably required to account for the peculiar tense and shining swelling 
which is so characteristic. "Whether this be an obstruction of the 
lymphatics, as Dr. Tilbury Fox and others have maintained with much 
show of reason, or whether it is some as yet undiscovered state, further 
investigation is required to show. But it is beyond any doubt that the 
important and essential part of the disease is the presence of a thrombus 
in the vessels ; and I think it will not be difficult to prove that in its 
causation and history it is precisely similar to the more serious cases in 
which the pulmonary arteries are involved. 

It will be well to commence the study of the subject by a considera- 
tion of the conditions which, in the puerperal state, render the blood 
so peculiarly liable to coagulation, and we may then proceed to discuss 
the symptoms and results of the formation of coagula in various parts 
of the circulatory system. 

Conditions which Favor Thrombosis. — The researches of Vir- 
chow, Benjamin Ball, Humphry, Richardson, and others have rendered 
us tolerably familiar with the conditions which favor the coagulation 
of the blood in the vessels. These are chiefly: 1. A stagnant or 
arrested circulation ; as, for example, when the blood coagulates in the 
veins which draw blood from the gluteal region in old and bedridden 
people, or, as in some forms of pulmonary thrombosis, in which the 
clots in the arteries are probably the result of obstruction in the circu- 
lation through the lung-capillaries, as in certain cases of emphysema, 
pneumonia, or pulmonary apoplexy. 2. A mechanical obstruction 
around which coagula form, as in certain morbid states of the vessels , 
or, a better example still, secondary coagula which form around a 
travelled embolus impacted in the pulmonary arteries. 3. And most 
important of all, in which the coagulation is the result of some morbid 
state of the blood itself. Examples of this last condition are fre- 
quently met with in the course of various diseases, such as rheumatism 
or fever, in which the quantity of fibrin is increased and the blood 



641 THE PUERPERAL STATE. 

itself is loaded with morbid material. Thrombosis from this cause is 
of by no means infrequent occurrence after severe surgical operations, 
especially such as have been attended with much hemorrhage, or when 
the patient is in a weak and anaemic coudition. This has been specially 
dwelt upon, as a not unfrequent source of death after operation, by 
Fayrer and other surgeons. 1 

Coagulation in the Puerperal State. — But little consideration is 
required to show why thrombosis plays so important a part in the 
puerperal state, for there most of the causes favoring its occurrence 
are present. Probably there is no other condition in which they exist 
in so marked a degree, or are so frequently combined. The blood 
contains an excess of fibrin, which largely increases in the latter 
months of utero-gestation, until, as has been pointed out by Andral 
and Gavarret, it not unfrequently contains a third more than the 
average amount present in the non-pregnant state. As soon as delivery 
is completed, other causes of blood-dyscrasia come into operation. 
Involution of the largely hypertrophied uterus commences, and the 
blood is charged with a quantity of effete material, which must be 
present in greater or less amount until that process is completed. It 
is an old observation that phlegmasia dolens is of very common occur- 
rence in patients who have lost much blood during labor. Thus Dr. 
Leishman says: "In no class of cases has it been so frequently 
observed as in women whose strength has been reduced to a low ebb 
by hemorrhage either during or after labor, and this, no doubt, 
accounts for the observation made by Merriman, that it is relatively a 
common occurrence after placenta prsevia." 2 An examination of the 
cases in which death results from pulmonary thrombosis shows the 
same facts, as in a large proportion of them severe post-partum hem- 
orrhage has occurred. The exhaustion following the excessive losses 
so common after labor must of itself strongly predispose to throm- 
bosis and, indeed, loss of blood has been distinctly pointed out by 
Richardson to be one of its most common antecedents. " There is," 
he observes, " a condition which has been long known to favor coagu- 
lation and fibrinous deposition. I mean loss of blood and syncope or 
exhaustion during impoverished states of the body." 

Since, then, so many of the predisposing causes of thrombosis are 
present in the puerperal state, it is hardly a matter of astonishment 
that it should be of frequent occurrence or that it should lead to con- 
ditions of serious gravity. And }^et the attention of the profession 
has been for the most part limited to a study of only one of the results 
of this tendency to blood-clotting after delivery, no doubt because of its 
comparative frequency and evident symptoms. True, the balance of 
professional opinion has lately held that phlegmasia dolens is chiefly 
the result of some morbid condition of the blood, producing plugging 
of the veins ; but the wider view which I am attempting to maintain, 
which would bring this disease into close relation with the more rarely 
observed, but infinitely important, obstructions of the pulmonary 
arteries, has scarcely, if at all, been insisted on. Doubtless further 

i Edin. Med. Journ., March, 1861 ; Indian Annals of Med., July, 1867. 
2 Leishman : System of Obstetrics, p. 720. Second edition, 1876. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 645 

investigation will show that it is not in these parts of the venous 
system alone that puerperal thrombosis occurs; but the symptoms and 
effects of venous obstruction elsewhere, important though they may 
be, are unknown. 

Distinction between Thrombosis and Embolism. — I propose, 
then, to describe the symptoms and pathology of blood-clot in the 
right side of the heart and pulmonary artery. It may be useful here 
to repeat that this is essentially distinct from embolism of the same 
parts. The latter is obstruction due to the impaction of a separated 
portion of a thrombus formed elsewhere, and for its production it is 
essential that thrombosis should have preceded it. Embolism is, in 
fact, an accident of thrombosis, not a primary affection. The condi- 
tion we are now discussing I hold to be primary, precisely similar in 
its causation to the venous obstruction which, in other situations, gives 
rise to phlegmasia dolens. 

At the threshold of this inquiry we have to meet the objection 
started by several who have written on this subject, 1 that spontaneous 
coagulation of the blood in the right side of the heart and pulmonary 
arteries is a mechanical and physiological impossibility. This was 
the view of Virchow, who, with his followers, maintained that when- 
ever death from pulmonary obstruction occurred, an embolus was of 
necessity the starting-point of the malady and the nucleus round 
which secondary deposition of fibrin took place. Virchow holds that 
the primary factor in thrombosis is a stagnant state of the blood, and 
that the impulse imparted to the blood by the right ventricle is of 
itself sufficient to prevent coagulation. It is to be observed that these 
objections are purely theoretical. Without denying that there is con- 
siderable force in the arguments adduced, I think that the clinical 
history of these cases strongly favors the view of spontaneous coagu- 
lation ; and I would apply to the theoretical objections advanced the 
argument used by one of their strongest upholders with regard to 
another disputed point : " Je pref ere laisser la parole aux faits, car 
devant eux la theorie s'incline." 2 

The anatomical arrangement of the pulmonary arteries shows how 
spontaneous coagulation may be favored in them; for, as Humphry 
has pointed out, 3 "the artery breaks up at once into a number of 
branches, which radiate from it, at different angles to the several parts 
of the lungs. Consequently a large extent of surface is presented to 
the blood, and there are numerous angular projections into the cur- 
rents, both which conditions are calculated to induce the spontaneous 
coagulation of the fibrin." We know also that thrombosis generally 
occurs in patients of feeble constitution, often debilitated by hemor- 
rhage, in whom the action of the heart is much weakened. These 
facts of themselves go far to meet the objections of those who deny 
the possibility of spontaneous coagulation at the roots of the pulmo- 
nary arteries. 

Results of Post-mortem Examinations. — The records of post- 

1 See especially Bertin : Des Embolies, p. 46 et seq. 

2 Bertin: Des Embolies, p. 149. 

3 Humphry : On the Coagulation of the Blood in the Venous System during Life. 



646 THE PUERPERAL STATE. 

mortem examinations show also that in many of the cases the right 
side of the heart, as well as the larger branches of the pulmonary 
arteries, contained firm, leathery, decolorized, and laminated coagula, 
which could not have been recently formed. The advocates of the 
purely embolic theory maintain that these are secondary coagula, 
formed round an embolus. But surely the mechanical causes which 
are sufficient to prevent spontaneous deposition of fibrin would also 
suffice to prevent its gathering round an embolus; unless, indeed, the 
obstruction was sufficient to arrest the circulation altogether, when 
death would occur before there was any time for a secondary deposit. 
Before we can admit the possibility of embolism we must have at least 
one factor — that is, thrombosis — in a peripheral vessel, from which an 
embolus can come. In many of the recorded cases nothing of the 
kind was found, and although, as is argued, this may have been over- 
looked, yet such an oversight can hardly always have been made. 

The strongest argument, however, in favor of the spontaneous origin 
of pulmonary thrombosis is one which I originally pointed out in a 
series of papers "On Thrombosis and Embolism of the Pulmonary 
Artery as a Cause of Death in the Puerperal State." l I there showed 
from a careful analysis of 25 cases of sudden death after delivery, in 
which accurate post-mortem examinations had been made, that cases 
of spontaneous thrombosis and embolism may be divided from each 
other by a clear line of demarcation, depending on the period after 
delivery at which the fatal result occurs. In 7 out of these cases there 
was distinct evidence of embolism, and in them death occurred at a 
remote period after delivery ; in none before the nineteenth day. This 
contrasts remarkably with the cases in which the post-mortem exami- 
nation afforded no evidence of embolism. These amounted to 15 out 
of the 25, and in all of them, w 7 ith one exception, death occurred 
before the fourteenth day, often on the second or third. The reason 
of this seems to be that, in the former, time is required to admit of 
degenerative changes taking place in the deposited fibrin leading to 
separation of an embolus; while in the latter the thrombosis corre- 
sponds in time, and to a great extent no doubt also in cause, to the 
original peripheral thrombosis from which, in the former, the embolus 
was derived. Many cases I have since collected illustrate the same 
rule in a very curious and instructive way. 

Another clinical fact I have observed points to the same conclusion. 
In one or two cases distinct signs of pulmonary obstruction have 
shown themselves without proving immediately fatal, and shortly 
afterward peripheral thrombosis, as evidenced by phlegmasia dolens 
of one extremity, has commenced. Here the peripheral thrombosis 
obviously followed the central, both being produced by identical 
causes, and the order of events necessary to uphold the purely embolic 
theory was reversed. 

I hold, then, that those who deny the possibility of spontaneous 
coagulation in the heart and pulmonary arteries do so on insufficient 
grounds, and that we may consider it to be an occurrence, rare no 

i Lancet, 1867. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 647 

doubt, but still sufficiently often met with, and certainly of sufficient 
importance, to merit very careful study. 

History. — Dr. Charles D. Meigs, of Philadelphia, was one of the 
first to direct attention to spontaneous coagulation of the blood in the 
right side of the heart and pulmonary arteries as a cause of sudden 
death in the puerperal state. The occurrence itself, however, has been 
carefully studied by Paget, whose paper was published in 1855, four 
years before Meigs wrote on the subject. 1 It is true that none of 
Paget's cases happened after delivery, but he none the less clearly 
apprehended the nature of the obstruction. In 1855, Hecker 2 attrib- 
uted the majority of these cases to embolism proper ; and since that 
date most authors have taken the same view, believing that sponta- 
neous coagulation only occurs in exceptional cases, such as those in 
which, on account of some obstruction in the lung or in the debility 
of the last few hours before death, coagula form in the smaller rami- 
fications of the pulmonary arteries, and gradually creep back toward 
the heart. 

Symptoms of Pulmonary Obstruction. — The symptoms can 
hardly be mistaken, and there seems to be no essential difference 
between the symptomatology of spontaneous and embolic obstructions, 
so that the same description will suffice for both. In a large propor- 
tion of cases the attack comes on with an appalling suddenness, which 
forms one of its most striking characteristics. Nothing in the con- 
dition of the patient need have given rise to the least suspicion of 
impending mischief, when all at once an intense and horrible dyspnoea 
comes on ; she gasps and struggles for breath ; tears off the coverings 
from her chest in a vain endeavor to get more air ; and often dies in 
a few minutes, long before medical aid can be had, with all the symp- 
toms of asphyxia. The muscles of the face and thorax are violently 
agitated in the attempt to oxygenate the blood, and an appearance 
closely resembling an epileptic convulsion may be presented. The 
face may be either pale or deeply cyauosed. Thus, in one case I have 
elsewhere recorded, which was an undoubted example of true embolism, 
Mr. Pedler, the resident accoucheur at King's College Hospital, who 
was present during the attack, writes of the patient : 3 " She was suffer- 
ing from extreme dyspnoea, the countenance was excessively pale, her 
lips white, the face generally expressing deep anxiety." In another, 
which was probably an example of spontaneous thrombosis, 4 occurring 
on the twelfth day after delivery, it is stated : " The face had assumed 
a livid purple hue, which was so remarkable as to attract the attention 
both of the nurse and of her mother, who was with her." The extreme 
embarrassment of the circulation is shown by the tumultuous and 
irregular action of the heart in its endeavor to send the venous blood 
through the obstructed pulmonary arteries. Soon it gets exhausted, 
as shown by its feeble and fluttering beat. The pulse is thread-like 
aud nearly imperceptible, the respirations short and hurried,, but air 

1 Medico-Chirur. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352. Philadelphia Medical Ex- 
aminer, 1849. 
^ Deutsche Klinik, 1855. 
3 Brit. Med. Journ., vol. i. p. 232. * Obst. Trans., vol. xn. p. 194. 



648 THE PUERPERAL STATE. 

may be heard entering the lungs freely. The intelligence daring the 
struggle is unimpaired ; and the dreadful consciousness of impending 
death adds not a little to the patient's sufferings and to the terror of 
the scene. Such is an imperfect account of the symptoms, gathered 
from a record of what has been observed in fatal cases. It will be 
readily understood why, in the presence of so sudden and awful an 
attack, symptoms have not been recorded with the accuracy of ordinary 
clinical observation. 

Is Recovery Possible? — A question of great practical interest, 
which has been entirely overlooked by writers on the subject, is, Have 
we any ground for supposing that there is a possibility of recovery 
after symptoms of pulmonary obstruction have developed themselves ? 
That such a result must be of extreme rarity is beyond question ; but 
I have little doubt that in some few cases, entirely inexplicable on any 
other hypothesis, life is prolonged until the coagulum is absorbed and 
the pulmonary circulation restored. In order to admit of this it is, 
of course, essential that the obstruction be not sufficient to prevent the 
passage of a certain quantity of blood to the lungs to carry on the 
vital functions. The history of many cases tends to show that the 
obstructing clot was present for a considerable time before death, and 
that it was only when some sudden exertion was made, such as rising 
from bed or the like, calling for an increased supply of blood which 
could not pass through the occluded arteries, that the fatal symptoms 
manifested themselves. This was long ago pointed out by Paget, 1 who 
says : " The case proves that, in certain circumstances, a great part of 
the pulmonary circulation may be arrested in the course of a week (or 
a few days, more or less) without immediate danger to life, or any 
indication of what had happened." And after referring to some 
illustrative cases : " Yet in all these cases the characters of the clots 
by which the pulmonary arteries were obstructed showed plainly that 
they had been a week or more in the process of formation." If we 
admit the possibility of the continuance of life for a certain time, we 
must, I think, also admit the possibility, in a few rare cases, of eventual 
complete recovery. What is required is time for the absorption of 
the clot. In the peripheral venous system coagula are constantly 
removed by absorption. So strong, indeed, is the tendency to this, 
that Humphry observes with regard to it : " It appears that the blood 
is almost sure to revert to its natural channel in process of time." 2 
If, then, the obstruction be only partial, if sufficient blood pass to keep 
the patient alive, and a sudden supjjly of oxygenated blood is not 
demanded by any exertion which the embarrassed circulation is unable 
to meet, it is not inconceivable that the patient may live until the 
obstruction is removed. 

Illustrative Cases. — Such I believe to be the only explanation of 
certain cases, some of which, on any other hypothesis, it is impossible 
to understand. The symptoms are precisely those of pulmonary 
obstruction, and the description I have given above may be applied 
to them in every particular; and after repeated paroxysms, each of 

1 Op. cit., p. 358. 

2 Med.-Chir. Trans., vol. xxvii. p. 14. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 649 

which seems to threaten immediate dissolution, an eventual recovery 
takes place. What, then, I am entitled to ask, can the condition be, 
if not that which I suggest ? As the question I am considering has 
never, so far as I am aware, been treated of by any other writer, I 
may be permitted to state very briefly the facts of one or two of the 
cases on which I found my argument, some of which I have already 
published in detail elsewhere. 

K. H., delicate young lady. Labor easy First child. Profuse post-partum hemorrhage. Did 
well until the seventh day. during the whole of which she felt weak. Same day an alarming attack 
of dyspnoea came on. For several days she remained in a very critical condition, the slightest 
exertion bringing on the attacks. A slight blowing murmur heard for a few days at the base of 
the heart, then it disappeared. For two months patient remained in the same state. As long as 
she was in the recumbent position she felt pretty comfortable ; but any attempt at sitting up in 
bed, or any unusual exertion, immediately brought on the embarrassed respiration. During all 
this time it was found necessary to administer stimulants profusely to ward off the attacks. Event- 
ually the patient recovered completely. 

Q. F., aged forty-four years. Mother of twelve children. Confined on July 6th. On the eleventh 
day she went to bed feeling well. There was no swelling or discomfort of any kind about the 
lower extremities at this time. About 3.30 a.m. she was sitting up in bed, when she was suddenly 
attacked with an indescribable sense of oppression in the chest, and fell back in a semi-unconscious 
state, gasping for breath. She remained in a very critical condition, with the same symptoms of 
embarrassed respiration, for three days, when they gradually passed away. Two days after the 
attack phlegmasia dolens came on, the leg swelled, and remained so for several months. 

This case is an example of the fact I have already referred to, 
of phlegmasia dolens coming on after the symptoms of pulmonary 
obstruction had manifested themselves ; the inference being that both 
depended on similar causes operating on two distinct parts of the 
circulatory system. 1 

C H., aged twenty-four years. Confined of her first child on August 20, 1867. Thirty hours after 
delivery she complained of great weakness and dyspnoea. This was alleviated by the treatment 
employed, but on the ninth day, after making a sudden exertion, the dyspnoea returned with in- 
creased violence, and continued unabated until I saw tne patient on September 4th, fourteen days 
after her confinement. The following are the notes of her condition, made at the time of her 
visit: "I found her sitting on the sofa, propped up with pillows, as she said she could not 
breathe in the recumbent position. The least excitement or talking brought on the most aggra- 
vated dyspnoea, which was so bad as to threaten almost instant death. Her sufferings during these 
paroxysms were terrible to witness. She panted and struggled for breath, and her chest heaved 
Avith short gasping respirations. She could not even bear anyone to stand in front of her, waving 
them awav with her hand, and calling for more air. These attacks were very frequent, and were 
brought oh bv the most trivial causes. She talked in a low, suppressed voice", as if she could not 
spare breath for articulation. On auscultation air was found to enter the lungs freely in every 
direction, both in front and behind. Immediately over the site of the pulmonary arteries there 
was a distinct harsh, rasping murmur, confined to a very limited space, and not propagated either 
upward or downward. The heart-sounds were feeble and tumultuous." These symptoms led me 
to diagnose pulmonary obstruction, and I of course gave a most unfavorable prognosis, but to 
mv great surprise the patient slowly recovered. I saw her again six weeks later, when her heart- 
sounds were regular and distinct and the murmur had completely disappeared. 

K E., aged forty-two years, was confined for the first time on November 5, 1873, in the sixth 
month of utero-gestation. She had severe post-partum hemorrhage, depending on partially ad- 
herent placenta, which was removed artificiallv. She. did perfectly well until the fourteenth day 
after delivery, when she was suddenly attacked with intense dyspnoea, aggravated in paroxysms. 
Pulse pretty full, 130, but distinctly intermittent. Air entered lungs ireely, The heart's action 
was fluttering and irregular, and at the juncture of the fourth and fifth ribs with the sternum 
there was a loud blowing systolic murmur. This was certainly non-existent before, as the heart 
had been carefully auscultated before administering chloroform during labor. For two days the 
patient remained in the same state, her death being almost momentarily expected. On the 21st— 
that is, two days after the appearance of the chest symptoms— phlegmasia dolens of a severe kind 
developed itself in the right thigh and leg. She continued in the same state for many days, lying 
more or less tranquilly, but having paroxysms of the most intense apncea, varving from two to 
six or eight in the twentv-four hours. No" one who saw her In one of these could have expected 
her to live through it. Shortly after the first appearance of the paroxysms it was observed that 
the cellular tissue of the neck and part of the face became swollen and (edematous, giving an 
appearance not unlike that of phlegmasia dolens, The attacks were always relieved by stimu- 
lants. These she incessantly called for, declaring that she felt that they kept her alive. During 



1 An interesting example of this occurrence has been kindly communicated to me by Dr. Neville, 
of Bristol. The patient, a primipara, aged twenty years, was suddenly seized with well-marked 
svmptoms of pulmonary obstruction on January 24, 1892, three days before delivery. She was con- 
fined on the 27th, her "condition from apncea being then so critical that death was momentarily 
expected. Thirty hours after delivery symptoms of phlegmasia dolens, with painful swelling of 
both legs and thighs, occurred. After a protracted illness the patient gradually recovered. This 
case is of special interest, since the svmptoms of pulmonary obstruction occurred before delivery. 
The onlv other instance of the same kind I know of has been recently recorded by Dr. Church 
(Trans, of the Obstet. Soc. of Edin., vol. xvii. p. 211), and that ended fatally. 



650 THE PUERPERAL STATE. 

all this time the mind was clear and collected. The pulse varied from 110 to 130 ; respirations 
about 60 ; temperature 101° to 102.5°. By slow degrees the patient seemed to be rallying. The 
paroxysms diminished in number, and after December 1st she never had another, and the breath- 
ing became tree and easy. The pulse fell to 80, and the cardiac murmur entirely disappeared. 
The patient remained, however, very weak and feeble, and the debility seemed to increase. 
Toward the second week in December she became delirious, and died, apparently exhausted, 
without any fresh chest symptoms, on the 19th of that month. No post-mortem examination was 
allowed. 

I have narrated this case, although it terminated fatally, because I 
hold it to be one of the class I am considering. The death was cer- 
tainly not due to the obstruction, all symptoms of which had disap- 
peared, but apparently to exhaustion from the severity of the former 
illness. It illustrates, too, the simultaneous appearance of symptoms 
of pulmonary obstruction and peripheral thrombosis. The swelling- 
of the neck was a curious symptom, which has not been recorded in 
any other cases, and may possibly be a further proof of the analogy 
between this condition and phlegmasia dolens. 

Such Cases can only Depend on Pulmonary Obstruction. — 
Now it may, of course, be argued that these cases do not prove my 
thesis, inasmuch as I only assume the presence of a coagulum. But 
I may fairly ask in return, What other condition could possibly explain 
the symptoms ? They are precisely those which are noticed in death 
from undoubted pulmonary obstruction. No one seeing one of them, 
or even reading an account of the symptoms, while ignorant of the 
result, could hesitate a single instant in the diagnosis. Surely, then, 
the inference is fair that they depended on the same cause. In the 
very nature of things my hypothesis cannot be verified by post-mortem 
examination ; but there is at least one case on record in which, after 
similar symptoms, a clot was actually found. The case is related by 
Dr. Richardson. 1 It was that of a man who for weeks had symptoms 
precisely similar to those observed in the cases I have narrated. In 
one of his agonizing struggles for breath he died, and after death it 
was found " that a fibrinous band, having its hold in the ventricle, 
extended into the pulmonary artery." This observation proves to a 
certainty that life may continue for weeks after the depositing of 
a coagulum ; and, moreover, this condition was precisely what we 
should anticipate, since, of course, the obstructing coagulum must 
necessarily be small, otherwise the vital functions would be imme- 
diately arrested. 

Cardiac Murmurs in Pulmonary Obstruction. — There is a 
symptom noted in two of the above cases, and to a less extent in a 
third, which has not been mentioned in any account of fatal cases 
occurring after delivery, viz., a murmur over the site of the pulmonary 
arteries. It is a sign we should naturally expect, and very possibly it 
would be met with in fatal cases if attention were particularly directed 
to the point. In both these instances it was exceedingly well marked, 
and in both it entirely disappeared when the symptoms abated. The 
probability of such a murmur being audible in cases of thrombosis of 
the pulmonary artery has been recognized by one of our highest 
authorities in cardiac disease, who actually observed it in a non- 
puerperal case. In the last edition of his work on diseases of the 

1 Clinical Essays, p. 224 et seq. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 651 

heart, Dr. Walshe l says : " The only physical condition connected 
with the vessel itself would probably be systolic basic murmur follow- 
ing the course of the pulmonary main trunk and of its immediate 
divisions to the left and right of the sternum. This sign I most cer- 
tainly heard in an old gentleman whose life was brought to a sudden 
close in the course of an acute affection by coagulation in the pulmonary 
artery, and to a moderate extent in the right ventricle. 

Similar cases have, probably, been overlooked or misinterpreted. 
Many seem to have been attributed to shock, in the absence of a better 
explanation, a condition to which they bear no kiud of resemblance. 

Causes of Death. — The precise mode of death in pulmonary ob- 
struction, whether dependent on thrombosis or embolism, has given 
rise to considerable difference of opinion. Virchow attributes it to 
syncope, 2 depending on stoppage of the cardiac contraction. Panum, 3 
on the other hand, contests this view, maintaining that the heart con- 
tinues to beat even after all signs of life have ceased. Certainly 
tumultuous and irregular pulsations of the heart are prominent symp- 
toms in most of the recorded cases, and are not reconcilable with the 
idea of syncope. Pan urn's own theory is that death is the result of 
cerebral anaemia. Paget seems to think that the mode of death is 
altogether peculiar, in some respects resembling syncope, in others 
anseniia. Bertin, who has discussed the subject at great length, 
attributes the fatal result purely to asphyxia. The condition, indeed, is 
in all respects similar to that state, the oxygenation of the blood being 
prevented, not because air cannot get to the blood, but because blood 
cannot get to the air. The symptoms also seem best explained by this 
theory ; the intense dyspnoea, the terrible struggle for air, the preserva- 
tion of intelligence, the tumultuous action of the heart, are certainly 
not characteristic either of syncope or anaemia. 

Post-mortem Appearances of Clots. — The anatomical character 
of the clots seems to vary considerably. Ball, by whom they have 
been most carefully described, believes that they generally commence 
in the smaller ramifications of the arteries, extending backward toward 
the heart, and filling the vessels more or less completely. Toward its 
cardiac extremity the coagulum terminates in a rounded head, in which 
respect it resembles those spontaneously formed in the peripheral 
veins. It is non-adherent to the coats of the vessels, and the blood 
circulates, when it can do so at all, between it and the vascular walls. 
Such clots are white, dense, and of a homogeneous structure, consisting 
of layers of decolorized fibrin, firm at the periphery, where the fibrin 
has been most recently deposited, and softened in the centre where 
amylaceous or fatty degeneration has commenced. Ball maintains that 
if the coagulum have commenced in the larger branches of the arteries, 
it must have first begun in the ventricle and extended into them. 
According to Humphry the same changes take place in pulmonary as 
in peripheral thrombi, and they may become adherent to the walls of 
the vessels or converted into threads or bands. When the obstruct ion 
is due to embolism, provided the case is a well-marked one and the 

* Walshe : On Diseases of the Heart, 4th ed., 1873. 

2 Gesamm. Abhandl., 1862, p. 316. Virchow's Archiv, 1863 



652 THE PUERPERAL STATE. 

embolus of some size, the appearances presented are different. We 
have no longer a laminated and decolorized coagulurn, with a rounded 
head, similar to a peripheral thrombus. The obstruction in this case 
generally takes place at the point of bifurcation of the artery, and we 
there meet with a grayish-white mass, contrasting remarkably with 
the more recently deposited fibrin before and behind it. It may be 
that the form of the embolus shows that it has recently been separated 
from a clot elsewhere ; and in many cases it has been possible to fit the 
travelled portion to the extremity of the clot from which it has been 
broken. We may also, perhaps, find that the embolus has undergone 
an amount of retrograde metamorphosis corresponding with that of 
the peripheral thrombus from which we suppose it to have come, but 
differing from that of the more recently deposited fibrin around it. It 
must be admitted, however, that the anatomical peculiarities of the 
coagula will by no means always enable us to trace them to their true 
origin. In many cases emboli may escape detection from their small- 
ness or from the quantity of fibrin surrounding them. 

Treatment. — But few words need be said as to the treatment of 
pulmonary obstruction. In a large majority of cases the fatal result 
so rapidly follows the appearance of the symptoms that no time is 
given us even to make an attempt to alleviate the patient's sufferings. 
Should we meet with a case not immediately fatal, it seems that there 
are but two indications of treatment affording the slightest rational 
ground of hope. 

1. To keep the patient alive by the administration of stimulants — 
brandy, ether, ammonia, and the like — to be repeated at intervals cor- 
responding to the intensity of the paroxysms and the results produced. 
In the cases I have above narrated, in which recovery ensued, this 
took the place of all other medication. Possibly leeches, or dry cup- 
ping to the chest, mig-ht prove of some service in relieving the circu- 
lation. 

2. To enjoin the most absolute and complete repose. The object of 
this is evident. The only chance for the patient seems to be that the 
vital functions should be carried on until the coagulum has been 
absorbed, or at least until it has been so much lessened in size as to 
admit of blood passing it to the lungs. The slightest movements may 
give rise to a fatal paroxysm of dyspnoea, from the increased supply of 
oxygenated blood required. It must not be forgotten that in a large 
proportion of cases death immediately followed some exertion in itself 
trivial, such as rising out of bed. Too much attention., then, cannot 
be given to this point. The patient should be kept absolutely still ; 
she should be fed with abundance of fluid food, such as milk, strong 
soups, and the like ; and she should on no account be permitted to 
raise herself in bed, or attempt the slightest muscular exertion. If we 
are fortunate enough to meet with a case apparently tending to recovery, 
these precautions must be carried on long after the severity of the 
symptoms has lessened, for a moment's imprudence may suffice to 
bring them back in all their original intensity. 

Bertin, 1 indeed, recommends a system of treatment very different 

1 Op. cit., p. 393. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 653 

from this. In the vain hope that the violent effort induced may cause 
the displacement of the impacted embolus (to which alone he attributes 
pulmonary obstruction), he recommends the administration of emetics. 
Few, I fancy, will be found bold enough to attempt so hazardous a 
plan of treatment. 

Various druffs have been suggested in these cases. Richardson 1 
recommended ammonia, a deficiency of which he at that time believed 
to be the chief cause of coagulation. He has since advised that liquor 
ammonioe should be given in large doses, twenty minims every hour, 
in the hope of causing solution of the deposited fibrin ; and he has 
stated that he has seen good results from the practice. Others advise 
the administration of alkalies, in the hope that they may favor 
absorption. The best that can be said for them is that they are not 
likely to do much harm. The inhalation of oxygen, which has been 
used with great success in severe pneumonia, 2 is obviously a hopeful 
remedy in this condition, and is well worthy of trial. 

Puerperal Pleuro-pneumonia. — This is, perhaps, the best place to 
mention an important but little understood class of cases which I 
believe to be less uncommon than is generally supposed. I refer to 
severe pleuro-pneumonia occurring in connection with the puerperal 
state, but not distinctly associated with septicaemia. Two carefully 
observed cases of this kind are recorded by MacDonald, occurring in 
his practice ; I myself have met with three very marked examples 
within the past three years, one of which proved fatal, the other two 
giving rise to most serious illness, from which the patient recovered 
with difficulty. 

So far as my own observation goes there are marked peculiarities in 
such cases which clearly differentiate them from the ordinary course of 
pneumonia. The onset is sudden and unconnected with exposure to 
cold or other cause of lung disease ; there is no definite crisis, but a 
continuous pyrexia of moderate intensity lasting a variable time ; and 
the physical signs differ from those of ordinary pneumonia. 

Physical Signs. — In MacDonald's case, as well as in my own, they 
w r ere peculiar in this respect, that there was very slight crepitation, 
marked rusty sputum, and a wooden dulness, much more intense than 
in ordinary pneumonia, extending over a large lung space, with a very 
slight entrance of air into the lung tissue. It is also remarkable that 
a very large proportion of the cases were associated with phlegmasia 
dolens. Thus it existed in one of MacDonald's two cases, and in two 
out of my own three. Like phlegmasia dolens, moreover, the disease 
generally commenced some weeks after delivery ; my own cases, for 
example, occurred respectively fifteen, twenty-eight, and thirty-five 
days after labor. It is difficult to believe that there is not some 
connection between these two conditions, and there is much in their 
peculiar history to lead to the belief that such forms of lung disease 
depend, in fact, on the thrombotic or embolic obstruction of the minute 
branches of the pulmonary arteries, caused by conditions similar to 
those which have produced the phlebitic obstructions in the lower 

1 Heart Disease during Pregnancy, p. 209. 

2 On the Use of Oxygen and Strychnia in Pneumonia," Brit. Med. Journ., January 23, 1892. 



654 THE PUERPERAL STATE. 

extremities. In the absence of careful post-mortem examination this 
hypothesis is clearly not susceptible of proof. MacDonald, while 
admitting that " a limited thrombosis of the pulmonary arteries would 
no doubt explain the facts of the cases," is rather inclined to " seek 
the chief explanation of their occurrence in the alterations Avhich the 
pregnant and puerperal conditions impress upon the blood and the 
blood-vascular system." 

I confess that to my mind the former hypothesis is not only the 
most definite, but the one which most readily explains all the pecu- 
liarities of these cases. I cannot, however, do more thau suggest it, 
in the hope that further observations, and especially carefully con- 
ducted autopsies, may throw some light on this obscure and little- 
studied subject. 

Treatment. — As regards treatment, it is obvious that it must be 
conducted on general principles, carefully avoiding over-severe meas- 
ures, and supporting the patient through a trial to the system that 
must necessarily be severe. 



CHAPTEE VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

Arterial Thrombosis and Embolism. — The same condition of the 
blood which so strongly predisposes to coagulation in the vessels 
through which venous blood circulates tends to similar results in the 
arterial system. These, however, are by no means so common, and 
do not, as a rule, lead to such important consequences. The subject 
has been but little studied, and almost all our knowledge of it is 
derived from a very interesting essay by Sir James Simpson. 1 As I 
have devoted so much space to the consideration of venous thrombosis 
and embolism, I shall but briefly consider the effects of arterial ob- 
struction. 

Causes. — In a considerable number of recorded cases the obstruc- 
tion has resulted from the detachment of vegetations deposited on the 
cardiac valves, the result of endocarditis, either produced by antecedent 
rheumatism or as a complication of the puerperal state. Sometimes 
the obstruction seems to depend on some general blood dyscrasia, 
similar to that producing venous thrombosis, or on some local change 
in the artery itself. Thus Simpson records a case apparently produced 
by local arteritis, which caused acute gangrene of both lower extremi- 
ties, ending fatally in the third week after delivery. In other cases it 
has been attributed to coagulation following sj)ontaneous laceration 
and corrugation of the internal coat of the artery. 

1 Selected Obstet. Works, vol. i. p. 523. 



PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 655 

Symptoms. — The symptoms of puerperal arterial obstruction must, 
of course, vary with the particular arteries affected. Those with the 
obstructiou of which we are most familiar are the cerebral, the brachial, 
aud the femoral. The effects produced must also be modified by the 
size of the embolus, aud the more or less complete obstruction it pro- 
duces. Thus, for example, if the middle cerebral artery be blocked 
up entirely, the functions of those portions of the brain supplied by it 
will be more or less completely arrested, and hemiplegia of the oppo- 
site side of the body, followed by softening of the brain texture, will 
probably result. If the nervous symptoms be developed gradually, 
or increase in intensity after their first appearance, it may be that an 
obstruction, at first incomplete, lias increased by the deposition of 
fibrin around it. So the occasional sudden supervention of blindness, 
with destruction of the eyeball — cases of which are recorded by 
Simpson — not improbably depend on the occlusion of the ophthalmic 
artery, the function of the organ depending on its supply through the 
single artery. The effects of obstruction of the visceral arteries in 
the puerperal state are entirely unknown, but it is far from unlikely 
that further investigation may prove them to be of great importance. 
In the extremities arterial obstruction produces effects which are well 
marked. They are classified by Simpson under the following heads : 
1. Arrest of pulse below the site of obstruction. This has been observed 
to come on either suddenly or gradually, and, if the occlusion be in 
one of the large arterial trunks, it is a symptom which a careful ex- 
amination will readily enable us to detect. 2. Increased force of 
pulsation in the arteries above the seat of obstruction. 3. Fall in the 
temperature of the limb. This is a symptom which is easily appreciable 
by the thermometer, and when the main artery of the limb is occluded 
the coldness of the extremity is well marked. 4. Lesions of motor 
and sensory functions, paralysis, neuralgia, etc. Loss of power in 
the affected limb is often a prominent symptom, and when it comes 
on suddenly, and is complete, the main artery will probably be 
occluded. It may be diagnosed from paralysis depending on cerebral 
or spinal causes by the absence of head symptoms, by the history of 
the attack, and by the presence of other indications of arterial obstruc- 
tion, such as loss of pulsation in the artery, fall of temperature, etc. 
The sensory functions in these cases are generally also seriously dis- 
turbed, not so much by loss of sensation as by severe pain and neur- 
algia. Sometimes the pain has been excessive, and occasionally it has 
been the first symptom which directed attention to the state of the 
limb. 5. Gangrene below or beyond the seat of arterial obstruction. 
Several interesting cases are recorded in which gangrene has followed 
arterial obstruction. Generally speaking, gangrene will not follow 
occlusion of the main arterial trunk of an extremity, as the collateral 
circulation soon becomes sufficiently developed to maintain its vitality. 
In many of the cases either thrombi have obstructed the channels of 
collateral circulation as well, or the veins of the limb have also been 
blocked up. AVhen such extensive obstructions occur, they obviously 
cannot be embolic, but must depend on a local thrombosis, traceable 
to some general blood dyscrasia depending <>n the puerperal state. 



656 THE PUERPERAL STATE. 

Treatment. — Little can be said as to the treatment of such cases, 
which must vary with the gravity and nature of the symptoms iu 
each. Beyond absolute rest (in the hope of eventual absorption of the 
thrombus or embolus), geuerous diet, attention to the general health 
of the patient, aud sedative applications to relieve the local pain, there 
is little in our power. Should gangrene of an extremity supervene in 
a puerperal patient, the case must necessarily be well-nigh hopeless. 
Simpson, however, records one instance in which amputation was per- 
formed above the line of demarcation, the patient eventually recovering. 



CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND 
THE PUERPERAL STATE. 

A large number of the cases in which sudden death occurs during 
or after delivery find their explanation, as I have already pointed out, 
in thrombosis or embolism of the heart and pulmonary arteries. 
Probably many cases of the so-called idiopathic asphyxia were, in fact, 
examples of this accident, the true nature of which had been mis- 
understood. Besides these, there are, no doubt, many other condi- 
tions which may lead to a suddenly fatal result in connection with 
parturition. 

Some of these are of an organic, others of a functional nature. 

Organic Causes. — Among the former may be mentioned cases in 
which the straining efforts of the second stage of labor have produced 
death in patients suffering from some pre-existent disease of the heart. 
Rupture of that organ has probably occurred from fatty degeneration 
of its walls. Dehous 1 narrates an instance in which the efforts of 
labor caused the rupture of an aneurism. Another case, from inter- 
ference with the action of the heart in a patient who had pericardial 
effusion, is narrated by Ramsbotham. Dr. Devilliers relates an 
instance occurring in a young woman during the second stage of 
labor. The heart was found to be healthy, but the lungs were in- 
tensely congested and blood was extensively extravasated all through 
their texture. This was probably caused by pulmonary congestion 
and apoplexy, produced by the severe straining efforts. Many cases 
from effusion of blood into the brain substance, or on its surface, are 
on record — no doubt in patients who, from arterial degeneration or 
other causes, were predisposed to apoplectic effusions. The so-called 
apoplectic convulsions, formerly described in most works on obstetrics 
as a variety of puerperal convulsions, are evidently nothing more than 

1 Dehous : Sur les Morts subites. 



CAUSES OF SUDDEN DEATH DURING LABOR. 657 

apoplexy coming on during or after labor. As regards their path- 
ology, they do not seem to differ from ordinary eases of apoplexy in 
the non-pregnant condition. One example is recorded of death which 
was attributed to rapture of the diaphragm from excessive action in 
the second stage. 

Functional Causes. — Among the causes of death which cannot be 
traced to some distinct organic lesion may be classed cases of syncope, 
shock, and exhaustion. Many instances of this kind are recorded. 
Thus in some women of susceptible nervous organization the severity of 
the suffering appears to bring on a condition similar to that produced 
by excessive shock or exhaustion, which has not unfrequently proved 
fatal. Several examples of this kind have been cited by McClintock. 1 
It is also not unlikely that sudden syncope sometimes produces a fatal 
result during or after labor. Most cases of death otherwise inex- 
plicable used to be referred to this cause ; but accurate autopsies 
were seldom made, and even when they were — the important effects of 
pulmonary coagula being unknown — it is more than probable that the 
true cause of death was overlooked. It has been supposed that the 
sudden removal of pressure from the veins of the abdomen, by the 
emptying of the gravid uterus after delivery, may favor an increased 
afflux of blood into the lower parts of the body, and thus tend to an 
anaemic condition of the brain and the production of syncope. How- 
ever this may be, the possibility of its occurrence, and its manifest 
danger in a recentlv delivered woman, are sufficient reasons for en- 
forcing the recumbent position after labor is over. In some of the 
cases the syncope was evidently produced by the patient suddenly 
sitting upright. 

Death from Air in the Veins. — Some cases of sudden death imme- 
diately after labor seem to be due to the entrance of air into the veins. 
Six examples are cited by McClintock which were probably due to 
this cause. La Chapelle related two. An interesting case is related 
by M. Lionet. 2 In this the patient died five and a half hours after 
an easy and natural labor, the chief symptoms being extreme pallor, 
efforts at vomiting, and dyspnoea. Air was found in the heart and in 
the arachnoid veins. There can be no question that the uterine 
sinuses after delivery are nearly as well adapted as the veins of the 
neck for allowing the entrance of air. They are firmly attached to 
the muscular walls of the uterus, so that they gape open when that 
organ is relaxed, and it is easy to understand how air might enter. 
Indeed, in the post-mortem examination in one of the cases occurring 
in the practice of Mme. La Chapelle, it is stated that " the uterine 
sinuses opened in the interior of the uterus by large orifices (one line 
and a half in diameter), through which air could readily be blown as 
far as the iliac veins, and vice versa" The condition of the uterus 
after delivery also enables the air to have ready access to the mouths 
of the sinuses, for the alternate relaxation and contraction of the uterus, 
occurring after the placenta is expelled, would tend to draw in the air 
as by a suction-pump. Hence an additional reason for insisting on 

i Union Med., 1853. * Dehous: op. cit., p. 58. 

42 



658 THE PUERPERAL STATE. 

firm contraction of the uterus, as this will lessen the risk of this 
accident. 

The precise mechanism of death from air in the veins has been a 
subject of dispute among pathologists. By Bichat 1 it was referred to 
ansemia and syncope for want of blood in the vessels of the brain, 
which are occupied by air. ISTysten 2 attributed it to distention of the 
cavities of the heart by rarefied air, producing paralysis of its wall ; 
Leroy, to a stoppage of the pulmonary circulation and consequent 
want of proper blood-supply to the left heart ; while Leroy d'Etoilles 
thought it might depend on any of these causes or a combination of 
all of them. These, and many other hypotheses on the subject, have 
been advanced, to all of which serious objection could be raised. The 
theory maintained by Yirchow and Oppolzer, 3 and more recently by 
Feltz, attributes the fatal results to impaction of the air-globules in the 
lesser divisions of the pulmonary arteries, where they form gaseous 
emboli, and cause death exactly in the same way as when the obstruc- 
tion depends on a fibrinous embolus. The symptoms observed in fatal 
cases closely correspond to those of pulmonary obstruction, and it is 
not unlikely that some cases attributed to other causes, may really 
depend on the entrance of air through the uterine sinuses. Such, for 
example, was most probably the explanation of a case referred to by 
Dr. Graily Hewitt in a discussion at the Obstetrical Society. 4 Death 
occurred shortly after the removal of an adjacent placenta, during 
which, no doubt, air could readily enter the uterine cavity. The 
symptoms, viz., u severe pain in the cardiac region, distress as regards 
respiration, and pulselessness," are identical with those of pulmonary 
obstruction. Dr. Hewitt refers the death to shock, which certainly 
does not generally produce such phenomena. 

1 Recherches sur la Vie et la Mort, 1853. 

2 Recherches de Phys. et Chim. Path., 1811. 

3 Kasuistik der Embolien ; Wiener med. Wocheusehr., 1862 : Ltss ifimbolies capillaires, 1868 : and 
op. cit., p. 115. 

4 Obst. Trans., vol. x. p. 28. 



PERIPHERAL VENOUS THROMBOSIS. 659 



CHAPTER IX. 

PERIPHERAL VENOUS THROMBOSIS— (Syn. : CRURAL PHLEBITIS 

—PHLEGMASIA DOLENS— ANASARCA SEROSA— (EDEMA 

LACTEUM— WHITE LEG, Etc.). 

Peripheral Thrombosis. — We now come to discuss the symptoms 
and pathology of the conditions associated with the formation of 
thrombi in the peripheral venous system, or rather in the veins of the 
lower extremities, since too little is known of their occurrence in other 
parts to enable us to say anything on the subject. 

The most important of these is the well-known disease which, under 
the name of phlegmasia dolens, has attracted much attention and given 
rise to numerous theories as to its nature and pathology. In describing 
it as a local manifestation of a general blood dyscrasia, and not as an 
essential local disease, I am making an assumption as to its pathology 
that many eminent authorities would not consider justifiable. I have, 
however, already stated some of the reasons for so doing, aud I hope 
to show shortly that this view is not incompatible with the most 
probable explanation of the peculiar state of the affected limb. 

Symptoms. — The first symptom which usually attracts attention is 
severe pain in some part of the limb that is about to be affected. The 
character of the pain varies in different cases. In some it is extremely 
acute, and is most felt in the neighborhood of, and along the course of, 
the chief venous trunks. It may begin in the groin or hip and extend 
downward; or it may commence in the calf aud proceed upward toward 
the pelvis. The pain abates somewhat after swelling of the limb 
(which generally begins within twenty-four hours), but it is always a 
distressing symptom, and continues as long as the acute stage of the 
disease lasts. The restlessness, want of sleep, and suffering which it 
produces are sometimes excessive. Coincident with the pain, and 
sometimes preceding it, more or less malaise is experienced. The 
patient may for a day or two be restless, irritable, and out of sorts, 
without any very definite cause ; or the disease may be ushered in by 
a distinct rigor. Generally there is constitutional disturbance, varying 
with the intensity of the case. The pulse is rapid and weak, 120 or 
thereabouts; the temperature elevated from 101° to 102°, with an 
evening exacerbation. The patient is thirsty ; the tongue is glazed or 
white and loaded ; the bow T els constipated. In some few cases, when 
the local affection is slight, none of these constitutional symptoms are 
observed. 

Condition of the Affected Limb. — The characteristic swelling 
rapidly follows the commencement of the symptoms. It generally 
begins in the groin, whence it extends downward. It may be limited 



660 THE PUERPERAL STATE. 

to the thigh ; or the whole limb, even to the feet, may be implicated. 
More rarely it commences in the calf of the leg, extending upward to 
the thigh and downward to the feet. The affected parts have a peculiar 
appearance which is pathognomonic of the disease. They are hard, 
tense, and brawny ; of a shiny white color ; and not yielding on press- 
ure, except toward the beginning and end of the illness. The appear- 
ances presented are quite different from those of ordinary oedema. 
When the whole thigh is affected the limb is enormously increased 
in size. Frequently the venous trunks, especially the femoral and 
popliteal veins, are felt obstructed with coagula, and rolling under the 
linger. They are painful when handled, and in their course more or 
less redness is occasionally observed. Either leg may be attacked, but 
the left more frequently than the right. There is a marked tendency 
for the disease to spread, and we often find, in a case which is progress- 
ing apparently well, a rise of temperature and an accession of febrile 
symptoms followed by the swelling of the other limb. 

Progress of the Disease. — After the acute stage has lasted from a 
week to a fortnight the constitutional disturbance becomes less marked, 
the pulse and temperature fall, the pain abates, and the sleeplessness 
and restlessness are less. The swelling and tension of the limb now 
begin to diminish and absorption commences. This is invariably a 
slow process. It is always many weeks before the effusion has disap- 
peared, and it may be many months. The limb retains for a length of 
time the peculiar wooden feeling, as Dr. Churchill terms it. Any im- 
prudence, such as a too early attempt at walking, may bring on a 
relapse and fresh swelling of the limb. This gradual recovery is by 
far the most common termination of the disease. In some rare cases 
suppuration may take place either in the subcutaneous cellular tissue, 
the lymphatic glands, or even in the joints, and death may result from 
exhaustion. The possibility of pulmonary obstruction and sudden 
death from separation of an embolus have already been pointed out, 
and the fact that this lamentable occurrence has generally followed 
some undue exertion should be borne in mind as a guide in the man- 
agement of our patient. 

Period of Commencement. — The disease usually begins within a 
short time after delivery, rarely before the second week. In 22 
cases tabulated by Dr. Robert Lee, 7 were attacked between the 
fourth and twelfth days, and 14 after the second week. Some cases 
have been described as commencing even months after delivery. It is 
questionable if these can be classed as puerperal, for it must not be 
forgotten that phlegmasia dolens is by no means necessarily a puerperal 
disease. There are many other conditions which may give rise to it, all 
of them, however, snch as produce a septic state of the blood, such as 
malignant disease, dysentery, phthisis, and the like. My own expe- 
rience would lead me to think that n^.ses of this kind are much more 
common than is generally believed. 

History and Pathology. — The disease has long attracted the 
attention of the profession. Passing over more or less obscure 
notices by Hippocrates, and others, we find the first clear account 
in the writings of Mauriceau, who not only gave a very accurate de- 



PERIPHERAL VENOUS THROMBOSIS. 661 

scription of its symptoms, but made a guess at its pathology, which 
was certainly more happy than the speculations of his successors ; it 
is, he says, caused " by a reflux on the parts of certain humors which 
ought to have been evacuated by the lochia." Puzos ascribed it to the 
arrest of the secretion of milk, and its extravasation in the affected 
limb. This theory, adopted by Levret and many subsequent writers, 
took a strong hold on both professional and public opinions, and to it 
we owe many of the names by which the disease is known to this day, 
such as oedema lacteum, milk leg, etc. In 1784 Mr. White, of Man- 
chester, attributed it to some morbid condition of the lymphatic glands 
and vessels of the affected parts ; and this or some analogous theory, 
such as that of rupture of the lymphatics crossing the pelvic brim, as 
maintained by Tyre, of Gloucester, or general inflammation of the 
absorbents, as held by Dr. Ferrier, was generally adopted. 

It was not until the year 1823 that attention was drawn to the con- 
dition of the veins. To Bouillaud belongs the undoubted merit of 
first pointing out that the veins of the affected limb were blocked up 
by coagula, although the fact had been previously observed by Dr. 
Davis, of University College. Dr. Davis made dissections of the veins 
in a fatal case, and found, as Bouillaud had done, that they were filled 
with coagula, which he assumed to be the results of inflammation of 
their coats; hence the name of crural phlebitis, which has been exten- 
sively adopted, instead of phlegmasia dolens. Dr. Robert Lee did 
much to favor this view ; and finding that thrombi were present in the 
iliac and uterine, as well as in the femoral, veins, he concluded that 
the phlebitis commenced in the uterine branches of the hypogastric 
veins and extended downward to the femorals. He pointed out that 
phlegmasia dolens was not limited to the puerperal state ; but that 
when it did occur independently of it, other causes of uterine phlebitis 
were present, such as cancer of the os and cervix uteri. The inflam- 
matory theory was pretty generally received, and even now is con- 
sidered by many to be a sufficient explanation of the disease. Indeed, 
the fact that more or less thrombosis was always present could not be 
denied ; and on the supposition that thrombosis could only be caused 
by phlebitis, as was long supposed to be the case, the inflammatory 
theory was the natural one. Before long, however, pathologists pointed 
out that thrombosis was by no means necessarily or even generally the 
result of inflammation of the vessels in which the clot was contained, 
but that the inflammation was more generally the result of the 
coa^ulum. 

The late Dr. Mackenzie took a prominent part in opposing the 
phlebitic theory. He proved by numerous experiments on the lower 
animals that inflammation is not sufficient of itself to produce the ex- 
tensive thrombi which are found to exist, and that inflammation 
originating in one part of a vein is not apt to spread along its canal, 
as the phlebitic theory assumes. His conclusion is that the origin of 
the disease is rather to be sought in some septic or altered condition of 
the blood, producing coagulation in the veins. Dr. Tyler Smith 1 

1 Tyler Smith : Manual of Obstetrics, p. 338. 



662 THE PUERPERAL STATE. 

pointed out an occasional analogy between the causes of phlegmasia 
dolens and puerperal fever, evidently recognizing the dependence of 
the former on blood dyscrasia. " I believe," he says, " that contagion 
and infection play a very important part in the production of the 
disease. I look on a woman attacked with phlegmasia dolens as 
having made a fortunate escape from the greater dangers of diifuse 
phlebitis or puerperal fever." In illustration of this he narrates the 
following instructive history : " A short time ago a friend of mine had 
been in close attendance on a patient dying of erysipelatous sore-throat 
with sloughing, and was himself affected with sore-throat. Under 
these circumstances he attended, within the space of twenty-four hours, 
three ladies in their confinements, all of whom were attacked with 
phlegmasia dolens." 

The latest important contribution to the pathology of the disease is 
contained in two papers by Dr. Tilbury Fox, published in the second 
volume of the Obstetrical Transactions. He maintained that some- 
thing beyond the mere presence of coagula in the veins is required to 
produce the phenomena of the disease, although he admitted that to be 
an important and even an essential part of the pathological changes 
present. The thrombi he believed to be produced either by extrinsic 
or intrinsic causes : the former comprising all cases of pressure by 
tumor or the like ; the latter, and the most important, being divisible 
into the heads of — 

1. True inflammatory changes in the vessels, as seen in the epidemic 
form of the disease. 

2. Simple thrombus produced by rapid absorption of morbid fluid. 

3. Virus action and thrombus conjoined, the phlegmasia dolens 
itself being the result of simple thrombus, and not produced by dis- 
eased (inflamed) coats of vessels ; the general symptoms the result of 
the general blood state. 

He further pointed out that the peculiar swelling of the limbs cannot 
be explained by the mere presence of oedema, from Avhich it is essen- 
tially different ; the white appearance of the skin, the severe neuralgic 
pain, and the persistent numbness indicating that the whole of the 
cutaneous textures, the cutis vera, and even the epithelial layer, are 
infiltrated with fibrinous deposit. He concluded, therefore, that the 
swelling is the result of oedema plus something else — that something 
being obstruction of the lymphatics, by which the absorption of 
effused serum is prevented. The efficient cause which produces these 
changes he believes to be, in the majority of cases, a septic action 
originating in the uterus, producing a condition similar to that in 
which phlegmasia dolens arises in the non-puerperal state. 

There is no doubt much force in Dr. Fox's arguments, and it may, 
I think, be conceded that obstruction of the veins per se is not sufficient 
to produce the peculiar appearance of the limb. It is, moreover, cer- 
tain that phlebitis alone is also an insufficient explanation not only of 
the symptoms but even of the presence of thrombi so extensive as those 
that are found. The view which traces the disease solely to inflam- 
mation or obstruction of lymphatics is purely theoretical, has no basis 
of facts to support it, and finds nowadays no supporters. The experi- 



PERIPHERAL VENOUS THROMBOSIS. 663 

ments of Mackenzie and Lee, as well as the vastly increased knowledge 
of the causes of thrombosis which the researches of modern pathologists 
have given us, seem to point strongly to the view already stated, that 
the disease can only be explained by a general blood dyscrasia de- 
pending on the puerperal state. It by no means follows that we are 
to consider Dr. Fox's speculations as incorrect. It is far from im- 
probable that the lymphatic vessels are implicated in the production 
of the peculiar swelling, only we are not as yet in a position to prove 
it. There is no inherent improbability in the supposition that the 
same morbid state of the blood which produces thrombosis in the veins 
may also give rise to such an amount of irritation in the lymphatics 
as may interfere with their functions and even obstruct them alto- 
gether. The essential and all-important point in the pathology of the 
disease, however, seems undoubtedly to be thrombosis in the veins ; 
and the probability of there being some as yet undetermined patho- 
logical changes in addition to this, by no means militates against the 
view I have taken of the intimate connection of the disease with other 
results of thrombosis in different vessels. 

Changes occurring- in the Thrombi. — The changes which take 
place in the thrombi all tend to their ultimate absorption. These 
have been described by various authors as leading to organization or 
suppuration. It is probable, however, that the appearances which 
have led to such a supposition are fallacious, and that they are really 
due to retrograde metamorphosis of the fibrin, generally of an amy- 
laceous or fatty character. 

Detachment of Emboli. — The peculiarities of a clot that must 
favor detachment of an embolus are such a shape as admits of a portion 
floating freely in the blood current by the force of which it is detached 
and carried to its ultimate destination. When the accident has occurred 
it is often possible to recognize the peripheral thrombus from which 
the embolus has separated, by the fact of its terminal extremity pre- 
senting a freshly fractured end, instead of the rounded head natural to 
it. Such detachment is unlikely to occur, even when favored by the 
shape of the clot, unless sufficient time has elapsed after its formation 
to admit of its softening and becoming brittle. The curious fact I 
have before mentioned, of true puerperal embolism occurring in the 
large majority of cases only after the nineteenth day from delivery, 
finds a ready explanation in this theory, which it remarkably cor- 
roborates. 

Treatment. — On the supposition that phlegmasia dolens was the 
result of inflammation of the veins of the affected limb, an antiphlo- 
gistic course of treatment was naturally adopted. Accordingly, most 
writers on the subject recommended depletion, generally by the appli- 
cation of leeches along the course of the affected vessels. AYe are told 
that if the pain continues, the leeches should be applied a second or 
even a third time. If we admit the septic origin of the disease, we 
must, I think, see the impropriety of such a practice. The fact that 
it occurs in a large majority of cases in patients of a weakly and 
debilitated constitution, often in women who have suffered from hemor- 
rhage, is a further reason for not adopting this routine custom. If 



664 THE PUERPERAL STATE. 

local loss of blood be used at all, it should be strictly limited to cases 
in which there is much tenderness and redness across the course of the 
veins, and then only in patients of plethoric habits and strong consti- 
tution. Cases of this kind will form a very small minority of those 
coming under our observation. 

What has been said of the pathology of the affection tends to the 
conclusion that active treatment of any kind, in the hope of curing 
the disease, is likely to be useless. Our chief reliance must be on 
time and perfect rest, in order to admit of the thrombi and the 
secondary effusion being absorbed, while we relieve the pain and other 
prominent symptoms and support the strength and improve the 
constitution of the patient. 

The constant application of heat and moisture to the affected limb 
will do much to lessen the tension and pain. Wrapping the entire 
limb in linseed-meal poultices, frequently changed, is one of the best 
means of meeting this indication. If, as is sometimes the case, the 
weight of the poultice be too great to be readily borne, we may sub- 
stitute warm flannel stupes covered with oiled silk. Local anodyne 
applications afford much relief, and may be advantageously used along 
with the poultices and stupes either by sprinkling their surface freely 
with laudanum or chloroform and belladonna liniment or by soaking 
the flannels in poppy-head fomentations. It is needless to say that 
the most absolute rest in bed should be enjoined, even in slight cases, 
and that the limb should be effectually guarded from undue pressure, 
by a cradle or some similar contrivance. Local counter-irritation has 
been strongly recommended, and frequent blisters have been considered 
by some to be almost specific. I should myself hesitate to use blisters, 
as they would certainly not be soothing applications, and one hardly 
sees how they can be of much service in hastening the absorption of 
the effusion. 

During the acute stage of the disease the constitutional treatment must 
be regulated by the condition of the patient. Light but nutrious diet 
must be administered in abundance, such as milk, beef-tea, and soups. 
Should there be much debility, stimulants in moderation may prove of 
service. With regard to medicines, we shall probably find benefit from 
such as are calculated to improve the condition of the blood and the 
general health of the patient. Chlorate of potash with diluted hydro- 
chloric acid, quinine either alone or in combination with carbonate of 
ammonia, the tincture of the perchloride of iron, are the drugs that are 
most likely to prove of service. Alkalies and other medicines, which 
have been recommended in the hope of hastening the absorption of 
coagula, must be considered as altogether useless. Pain must be 
relieved and sleep procured by the judicious use of anodynes, such as 
Dover's powder, the subcutaneous injection of morphia, or chloral. 
Generally no form answers so well as the hypodermic injection of mor- 
phin. 

When the acute symptoms have abated and the temperature has 
fallen, the poultices and stupes may be discontinued and the limbs 
swathed in a flannel roller from the toes upward. The equable pres- 
sure and support thus afforded materially aid the absorption of the 



PERIPHERAL VENOUS THROMBOSIS. 665 

effusion and tend to diminish the size of the limb. At a still later 
stage very gentle inunctions of weak iodine ointment may be used 
with advantage once a day before the roller is applied. Shampooing 
and friction of the limb, generally recommended for the purpose of 
hastening absorption, should be carefully avoided, on account of the 
possible risk of detaching a portion of the coagulum and producing 
embolism. This is no merely imaginary danger, as the following fact 
narrated by Trousseau proves : "A phlegmasia alba dolens had ap- 
peared on the left side in a young woman suffering from peri-uterine 
phlegmon. The pain having ceased, a thickened venous trunk was 
felt on the upper and internal part of the thigh. Rather strong 
pressure was being made, when M. Demarquay felt something yield 
under his fingers. A few minutes afterward the patient was attacked 
with dreadful palpitation, tumultuous cardiac action, and extreme 
pallor, and death was believed to be imminent. After some hours, 
however, the oppression ceased and the patient eventually recovered. 
A slightly attached coagulum must have become separated and con- 
veyed to the heart or pulmonary artery." 1 "Warm douches of water — 
of salt water, if it can be obtained — may be advantageously used in 
the later stages of the disease, and they may be applied night and 
morning, the limb being bandaged in the interval. The occasional 
use of the continuous current is said to promote absorption, and would 
seem likely to be a serviceable remedy. 

When the patient is well enough to be moved, a change of air to 
the seaside will be of value. Great caution, however, should be 
recommended in using the limb, and it is far better not to run the 
risk of a relapse by any undue haste in this respect. It is well to warn 
the patient and her friends that a considerable time must of necessity 
elapse before the local signs of the disease have completely disappeared. 
Sometimes mauy years elapse before this is the case. In one of my 
own patients, who had phlegmasia seventeen years ago, the affected 
limb is still practically unaltered. 

i Trousseau: CliDique de l'HOtel-Dieu, in Gaz. des Hop., 1860, p. 577. 



666 THE PUERPERAL STATE. 



CHAPTER. X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

Recognized from the Earliest Times. — From the earliest times 
the occurrence after parturition of severe forms of inflammatory 
disease in and about the pelvis, frequently ending in suppuration, 
has been well known. It is only of late years, however, that these 
diseases have been made the subject of accurate clinical and patho- 
logical investigation, and that their true nature has begun to be 
understood. Nor is our knowledge of them as yet by any means 
complete. They merit careful study on the part of the accoucheur, 
for they give rise to some of the most severe and protracted illnesses 
from which puerperal patients suffer. They are often obscure in their 
origin and apt to be overlooked, and they not rarely leave behind 
them lasting mischief. 

These diseases are not limited to the puerperal state. On the con- 
trary, many of the severest cases arise from causes altogether un- 
connected with childbearing. These will not be now considered, and 
this chapter deals solely with such forms as may be directly traced to 
childbirth. 

Modern researches have demonstrated that there are two distinct 
varieties of inflammatory disease met with after labor which differ 
materially from each other in many respects. In one of these the 
inflammation affects chiefly the connective tissue surrounding the 
generative organs contained within the pelvis, or extends up from 
beneath the peritoneum and into the iliac fossae. In the other it 
attacks that portion of the peritoneum which covers the pelvic viscera, 
and is limited to it. 

Variety of Nomenclature — So much is. admitted by all writers, 
although there has been and still is much difference of opinion as to 
the etiology of these diseases ; but great obscurity in description, and 
consequent difficulty in understanding satisfactorily the nature of these 
affections, have resulted from the variety of nomenclature which different 
authors have adopted. 

Thus the former disease has been variously described as pelvic cellu- 
litis, peri-uterine phlegmon, para-metritis, or pelvic abscess; the latter 
as pelvic peritonitis, or peri-metritis, as contradistinguished from para- 
metritis- The use of the prefix para or peri, to distinguish the cellular 
or peritoneal variety of inflammation, originally suggested by Virchow, 
has been generally adopted in Germany, and has been strongly advocated 
in Great Britain by Matthews Duncan. It has never, however, found 
much favor with English writers, and the similarity of the two names 
is so great as to lead to confusion. I have, therefore, selected the 
terms 'pelvic peritonitis and pelvic cellulitis as conveying in themselves 
a fairly accurate notion of the tissues mainly involved. 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 667 

Importance of Distinguishing" the Two Classes of Cases. — 
The important fact to remember is that there exist two distinct varieties 
of inflammatory disease presenting many similarities in their course, 
symptoms, and results, often occurring simultaneously, but in the main 
distinct in their pathology and capable of being differentiated. Thomas 
compares them — and, as serving to fix the facts on the memory, the 
illustration is a good one — to pleurisy and pneumonia. " Like thern," 
he says, " they are separate and distinct, like them affect different kinds 
of structure, and like them they generally complicate each other." It 
might, therefore, be advisable, as most writers on the disease occurring 
in the non-puerperal state have done, to treat of them in two separate 
chapters. There is, however, more difficulty in distinguishing them as 
puerperal than as non-puerperal affections, for which reason, as well as 
for the sake of brevity, I think it better to consider them together, 
pointing out as I proceed the distinctive peculiarities of each. 

Seat of Disease. — When attention was first directed to this class of 
diseases the pelvic cellular tissue was believed to be the only structure 
affected. This was the view maintained by Nonat, Simpson, and many 
modern writers. Attention was first prominently directed to the im- 
portance of localized inflammation of the peritoneum, and to the fact 
that many of the supposed cases of cellulitis were really peritonitic, 
by Bernutz. There can be no doubt that he here made an enormous 
step in advance. Like many authors, however, he rode his hobby a 
little too hard, and he erred in denying the occurrence of cellulitis in 
mauy cases in which it undoubtedly exists. In this respect he has 
been followed by many modern writers, who have dwelt specially on 
the fact that a large proportion of pelvic inflammations originated in 
diseased conditions of the Fallopian tubes, especially when these had 
been converted into pus sacs, and were secondary to them. That 
these views are accurate as to the great majority of pelvic inflamma- 
tions not immediately connected with and following parturition, I do 
not doubt. That type of disease, however, is not now under consid- 
eration, this chapter being concerned with puerperal cases only. 

Etiology. — The great influence of childbirth in producing these 
diseases has long been fully recognized. Courty estimates that about two- 
thirds of all the cases met with occur in connection with delivery or 
abortion, and Duncan found that out of 40 carefully observed cases 25 
were associated with the puerperal state. 

It is now generally admitted by most modern writers that both 
varieties of the disease are produced by the extension of inflammation 
from either the uterus, the Fallopian tubes, or the ovaries. This 
point has been especially insisted on by Duncan, who maintains that 
the disease is never idiopathic, and is " invariably secondary either to 
mechanical injury, or to the extension of inflammation of some of the 
pelvic viscera, or to the irritation of noxious discharges through or from 
the tubes or ovaries." 

Their intimate connection with puerperal septic conditions is also a 
prominent fact in the natural history of the diseases. Barker mentions 
a curious observation illustrative of this, that when puerperal fever is 
endemic in the Bellevue Hospital, in New York, cases of pelvic peri- 



668 THE PUERPERAL STATE. 

tonitis and cellulitis are also invariably met with. Olshausen has also 
remarked that in the Lying-in Hospital at Halle, daring the autumn 
vacation, when the patients are not attended by practitioners, and wheu, 
therefore, the chance of septic infection being conveyed to them is less, 
these inflammatious are almost always absent. As inflammation of the 
lining membrane of the uterus, of the vaginal mucous membraue, and 
of the pelvic connective tissue are of very constant occurrence as local 
phenomena of septic absorption, the connection between the two classes 
of cases is readily susceptible of explanation. Schroeder, indeed, goes 
further, and includes his description of these diseases under the head 
of puerperal fever. They do not, however, necessarily depend upon 
it; for, although it must be admitted that cases of this kind form a 
large proportion of those met with, others unquestionably occur which 
cannot be traced to such sources, but are the direct result of causes 
altogether unconnected with the inflammation attending on septic 
absorption, such as undue exertion shortly after delivery, or premature 
coition. Mechanical causes may beyond doubt excite the disease in a 
woman predisposed by the puerperal process, but such cases cannot 
fairly be included under the head of puerperal fever. There can be 
no question, however, of the infective origin of the vast majority of 
cases, and the corollary cannot be too strongly impressed on the prac- 
titioner that in strict antiseptic precautions we have the surest means 
of prevention. 

Seat of the Inflammation in Pelvic Cellulitis. — Abundance of 
areolar tissue exists in connection with the pelvic viscera, which may 
be the seat of cellulitis. It forms a loose padding between the organs 
contained in the pelvis proper, surrounds the vagina, the rectum, and 
the bladder, aud is found in considerable quantity between the folds of 
the broad ligaments. During pregnancy the broad ligaments are 
drawn up by the growing uterus, so that eventually they are entirely 
above the pelvic brim, and their place in the cavity is occupied by 
newly formed connective tissue, the amount of which is therefore 
greatly increased during gestation. From these parts it extends up- 
ward to the iliac fossse and the inner surface of the abdominal parietes. 
In any of these positions it may be the seat of the kind of inflamma- 
tion we are discussing. The essential character of the inflammation is 
similar to that which accompanies areolar inflammation in other parts 
of the body. There is first an acute inflammatory oedema, followed 
by infiltration of the areolae of the connective tissue with exudation, 
and the consequent formation of appreciable swellings. These may 
form in any part of the pelvis. Thus we may meet with them — and 
this is a very common situation — between the folds of the broad liga- 
ments, forming distinct hard tumors, connected with the uterus and 
extending to the pelvic walls, their rounded outlines being readily 
made out by bimanual examination. If the cellulitis be limited in 
extent, such a swelling may exist on one side of the uterus only, form- 
ing a rounded mass of varying size and apparently attached to it. At 
other times the exudation is more extensive, and may completely or 
partially surround the uterus, extending to the cellular tissue between 
the vagina aud rectum or between the uterus and the bladder. In 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 669 

such cases the uterus is imbedded and firmly fixed in dense, hard 
exudation. At other times the inflammation chiefly affects the cellular 
tissue covering the muscles lining the iliac fossae. There it forms a 
mass easily made out by palpation, but on vaginal examination little 
or no trace of the exudation can be felt, or only a sense of thickness at 
the roof of the vagina on the same side as the swelling. 

Seat of the Inflammation in Pelvic Peritonitis. — In pelvic peri- 
tonitis, which is much more ofteu met with unconnected with parturi- 
tion, the inflammation is limited to that portion of the peritoneum 
which invests the pelvic viscera. Its extent necessarily varies with 
the intensity and duration of the attack. In some cases there may be 
little more than irritation, while more often it runs on to exudation of 
plastic material. The result is generally complete fixation of the 
uterus and hardening and swelling in the roof of the vagina, and the 
lymph poured out may mat together the surrounding viscera, so as to 
form swellings, difficult, in some cases, to differentiate from those 
resulting from cellulitis. On post-motem examination the pelvic 
viscera are found extensively adherent, and the agglutination may 
involve the coils of the intestine in the vicinity, so as sometimes to 
form tumors of considerable size. 

Relative Frequency of the two forms of Disease. — The relative 
frequency of these two forms of inflammation as puerperal affections is 
not easy to ascertain. In the non-puerperal state the peritonitic variety 
is much the more common, and it is even open to question if cellulitis 
occurs there at all ; but in the puerperal state they very generally com- 
plicate each other, and it is rare for cellulitis to exist to any great 
extent without more or less peritonitis. 

Symptomatology. — The earliest symptom is pain in the lower part 
of the abdomen, which is generally preceded by rigor or chilliness. 
The amount of pain varies much. Sometimes it is comparatively 
slight, and it is by no means rare to meet with patients who are the 
subjects of very considerable exudations who suffer little more than a 
certain sense of weight and discomfort at the lower part of the abdo- 
men. On the other hand, the suffering may be excessive, and is char- 
acterized by paroxysmal exacerbations, the patient being comparatively 
free from pain for several successive hours, and then having attacks of 
the most acute agony. Schroeder says that pain is always a symptom 
of peritonitis, and that it does not exist in uncomplicated cellulitis. 
The swellings of cellulitis are certainly sometimes remarkably free 
from tenderness, and I have often seen masses of exudation in the iliac 
fossae which could bear even rough handling. On the other hand, 
although this is certainly more often met with in non-puerperal cases, 
the tenderness over the abdomen is sometimes excessive, the patient 
shrinking from the slightest touch. The pulse is raised, generally from 
100 to 120, and the thermometer shows the presence of pyrexia. Dur- 
ing the entire course of the disease both these symptoms continue. The 
temperature is often very high, but more frequently it varies from 100° 
to 104°, and it generally shows more or less marked remissions. In 
some cases the temperature is said not to be elevated at all. or even to 
be subnormal, but this is certainly quite exceptional. Other signs of 



670 THE PUERPERAL STATE. 

local and general irritation often exist. Among them, and most dis- 
tinctly in cases of peritonitis, are nausea and vomiting, and an anxious, 
pinched expression of the countenance, while the local mischief often 
causes distressing dysuria and tenesmus. The latter is especially apt 
to occur when there is exudation between the rectum and vagina which 
presses on the bowel. The passage of feces, unless in a very liquid 
form, may then cause intolerable suffering. When the connective tissue 
of the iliac fossa is affected, as is often the case, a characteristic symp- 
tom is flexion of the thigh on the pelvis, an instinctive position assumed 
by the patient to relieve tension. 

Such symptoms may show themselves within a few days after 
delivery, and then they can barely fail to attract attention. On the 
other hand, they may not commence for some weeks after labor, and 
then they are often insidious in their onset and apt to be over- 
looked. It is far from rare to meet with cases six weeks or more after 
confinement in which the patient complains of little beyond a feeling 
of malaise and discomfort, and in which, on investigation, a consider- 
able amount of exudation is detected which had previously entirely 
escaped observation. 

Results of Physical Examination. — On introducing the finger 
into the vagina it will be found to be hot and swollen, in some cases 
distinctly cedematous, and on reaching the vaginal cul-de-sac the exist- 
ence of exudation may generally be made out. The amount of this 
varies much. Sometimes, especially in the early stage of the disease, 
there is little more than a diffuse sense of thickness and induration at 
either side of, or behind, the uterus. More generally, careful bimanual 
examination enables us to detect a distinct hardening and swelling, 
possibly a tumor of considerable size, which may apparently be attached 
to the sides of the uterus and rise above the pelvic brim, or may extend 
quite to the pelvic walls. The examination should be very carefully 
and systematically conducted with both hands, so as to explore the 
whole contour of the uterus before, behind, and on either side, as well 
as the iliac fossae j otherwise a considerable exudation might readily 
escape detection. 

When the exudation is at all great, more or less fixity of the 
uterus is sure to exist, and this is a very characteristic symptom. 
The womb, instead of being freely movable by the examining finger, 
is firmly fixed by the surrounding exudation, and in severe forms 
of the disease is quite incased in it. More or less displacement 
of the organ is also of common occurrence. If the swelling be limited 
to one side of the pelvis or to Douglas's space, the uterus is displaced 
in the opposite direction, so that it is no longer in its usual central 
position. 

The differential diagnosis of pelvic cellulitis and pelvic peritonitis 
cannot always be made, and indeed in many cases it is impossible, 
since both varieties of disease coexist. The elements of differentiation 
generally insisted on are, the greater general disturbance, nausea, etc., 
in pelvic peritonitis, with an earlier commencement of the symptoms 
after labor. The swellings of pelvic peritonitis are also more tender, 
with less clearly defined outline than those of cellulitis. When the 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 671 

cellulitis involves the iliac fossa the diagnosis is, of course, easy, and 
then a continuous retraction of the thigh on the aifected side (an in- 
voluntary position assumed with the view of keeping the muscles 
lining the iliac fossa at rest) is often observed. When the inflam- 
mation is chiefly limited to the cavity of the pelvis, the distinction 
between the two classes of cases cannot be made with any degree of 
certainty. 

Terminations. — Both forms of disease may end either in resolution 
or in suppuration. In the former case, after the acute symptoms have 
existed for a variable time, it may be for a few days only, it may be 
for many weeks, their severity abates, the swellings become less tender 
and commence to contract, become harder, and are gradually absorbed, 
until at last the fixity of the uterus disappears and it again resumes 
its central position in the pelvic cavity. This process is often very 
gradual. It is by no means rare to find a patient, even some months 
after the attack, when all acute symptoms have long disappeared, who 
is even able to move about Avithout inconvenience, in whom the uterus 
is still immovably fixed in a mass of deposit, or is at least adherent 
in some part of its contour. More or less permanent adhesions are 
of common occurrence, and give rise to symptoms of considerable 
obscurity, which are often not traced to their proper source. 

Symptoms of Suppuration. — When the inflammation is about to 
terminate in suppuration, the pyrexial symptoms continue, and event- 
ually well-marked hectic is developed, the temperature generally show- 
ing a distinct exacerbation at night. At the same time rigors, loss of 
appetite, a peculiar yellowish discoloration of the face, and other signs 
of suppuration, show themselves. The relative frequency of this ter- 
mination is variously estimated by authors. Duncan quoted Simpson 
as calculating it to occur in half the cases of pelvic cellulitis, but 
stated his own belief that it is much more frequent. West observed it 
in 23 out of 43 cases following delivery or abortion, and McClintock 
in 37 out of 70. Schroeder said that he had only once seen suppura- 
tion in 92 cases of distinctly demonstrable exudation, a result which is 
certainly totally opposed to common experience. Barker also stated 
that in his experience suppuration in either pelvic peritonitis or cellu- 
litis " is very rare, except when they are associated with pyaemia or 
puerperal fever." It is certain that suppuration is more likely to 
occur in pelvic cellulitis than in pelvic peritonitis, but it unquestion- 
ably occurs, in Great Britain at least, much more frequently than the 
statements of either of these authors would lead us to suppose. 

Channels through which Pus may Escape. — The pus may find 
an exit through various channels. In pelvic cellulitis, more especially 
when the areolar tissue of the iliac fossa is implicated, the most com- 
mon site of exit is through the abdominal wall. It may, however, 
open at other positions, and the pus may find its way through the 
cellular tissue and point at the side of the anus or in the vagina, or it 
may take even a more tortuous course and reach the inner surface of 
the thigh. Pelvic abscesses not uncommonly open into the rectum or 
bladder, causing very considerable distress from tenesmus or dysuria. 
According to Hervieux, it is chiefly the peritoneal varieties which open 



672 THE PUERPERAL STATE. 

in this way. Not un frequently more than one opening is formed ; and 
when the pus has burrowed for any distance long fistulous tracts result 
which secrete pus for a length of time and are very slow to heal. 
Rupture of an abscess into the peritoneal cavity, especially of a peri- 
tonitic abscess, is a possible (but fortunately a very rare) termination, 
and will generally prove fatal by producing general peritonitis. In 
one case which I have recorded in the fifteenth volume of the Obstet- 
rical Transactions, suppuration was followed by extensive necrosis of 
the pelvic bones. Two similar cases are related by Trousseau in his 
Clinical Medicine, but I have not been able to meet with any other 
examples of this rare complication, which was probably rather the 
result of some obscure septic condition than of extension of the inflam- 
mation. 

Prognosis. — The prognosis is favorable as regards ultimate recovery, 
but there is great risk of a protracted illness which may seriously im- 
pair the health of the patient, especially if suppuration result. Hence 
it is necessary to be guarded in an expression of opinion as to the con- 
sequences of the disease. Secondary mischief is also far from unlikely 
to follow, from the physical changes produced by the exudation, such 
as permanent adhesions or malpositions of the uterus, or organic alter- 
ations in the ovaries or Fallopian tubes. 

Treatment. — In the treatment of both forms of disease the impor- 
tant points to bear in mind are the relief of pain and the necessity of 
absolute rest ; and to these objects all our measures must be subordinate, 
since it is quite hopeless to attempt to cut short the inflammation by 
any active medication. 

If the disease be recognized at a very early stage, the local abstrac- 
tion of blood by the application of a few leeches to the groin or to the 
hemorrhoidal veins may give relief; but the influence of this remedy 
lias been greatly exaggerated, and when the disease is of any standing 
it is quite useless. Leeches to the uterus, often recommended, are, I 
believe, likely to do more harm than good (unless in very skilful 
hands), from the irritation produced by passing the speculum. Opiates 
in large doses may be said to be our sheet-anchor in treatment when- 
ever the pain is at all severe, either by the mouth, in the form of 
morphia suppositories, or injected subcutaneously; but here, as in all 
cases in which opiates are required, care should be taken to minimize 
their use as much as possible. In the not uncommon cases in which 
pain comes on severely in paroxysms, the opiates should be admin- 
istered in sufficient quantity to lull the pain ; and it is a good plan 
to give the nurse a supply of morphia suppositories (which often 
act better than any other form of administering the drug), with 
directions to use them immediately the pain threatens to come on. 
When there is much pyrexia large doses of quinine may be given with 
great advantage along with the opiates. The state of the bowels 
requires careful attention. The opiates are apt to produce con- 
stipation, and the passage of hardened feces causes much suffering. 
Hence it is desirable to keep the bowels freely open. Nothing answers 
this purpose so well as small doses of castor oil, such as half a tea- 
spoonful given every morning. Warmth and moisture constantly 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 673 

applied to the lower part of the abdomen give great relief, either in 
the form of large poultices of Hd seed-meal, or, if these prove too heavy, 
of spoDgio-piline soaked in boiling water. The poultices may be 
advantageously sprinkled with laudanum or belladonna liniment. I 
say nothing of the use of mercurials, iodide of potassium, and other 
so-called absorbent remedies, since I believe them to be quite valueless 
and apt to divert attention from more useful plans of treatment. 

The most absolute rest in the recumbent position is essential, and it 
should be persevered in for some time after the intensity of the 
symptoms is lessened. The beneficial effect of rest in alleviating pain 
is often seen in neglected cases, the nature of which has been over- 
looked, instant relief following the laying up of the patient. 

When the acute symptoms have lessened, absorption of the exuda- 
tion may be favored and considerable relief obtained from counter- 
irritation, which should be gentle and long-continued. The daily use 
of tincture of iodine until the skin peels, perhaps best meets this indi- 
cation, but frequently repeated blisters are often very serviceable. 
This I believe to be a better plan than keeping up an open sore with 
savine ointment or similar irritating applications. 

When suppuration is established, the question of opening the abscess 
arises. When this points in the groin and the matter is superficial, a 
free incision may be made, under strict antiseptic precautions. The 
abscess should, however, not be opened too soon, and it is better to 
wait until the pus is near the surface. The importance of not being 
in too great a hurry to open pelvic abscesses has been insisted on by 
West, Dancan, and other writers, and I have no doubt the rule is a 
gODd one. It is more especially applicable when the abscess is pointing 
in the vagina or rectum, and then the presence of pus should be posi- 
tively ascertained before operating. We have in the aspirator a most 
useful instrument in the treatment of such cases, which enables us to 
ascertain the presence of pus without any risk, and the use of which 
is not attended with danger, even if employed prematurely. If it 
demonstrates its existence a free opening can afterward be safely made 
and a suitable drainage tube inserted into the abscess cavity. The 
surgical treatment of pelvic inflammations is, however, a very exten- 
sive subject, on which much difference of opinion exists. It cannot 
be considered in all its details here, and for its further study the reader 
must be referred to treatises on Gynecology.* 

The diet should be abundant, but simple and nutritious. In the 
earlv stages of the disease, milk, beef-tea, eggs, and the like will be 
sufficient. After suppuration a large quantity of animal food is nec- 
essary, and a sufficient amount of stimulants. The drain on the system 
is then often very great, and the amount of nourishment patients will 
require and assimilate, when a copious purulent discharge is going 
on, is often quite remarkable. A general tonic plan of medication is 
also indicated, and such drugs as iron, quinine, and cod-liver oil will 
prove useful. 

1 See Allbutt and Piayfair's " System of Gynecology," p. 485. 
43 



INDEX. 



4 BDOMEN, adipose enlargement of, 165 
A. enlargement of, as a sign of pregnancy, 

156 
Abdominal gestation, 181 
diagnosis of, 1 94 
exci&ion of cyst in, 197 
mode of performing operation in, 

196 
treatment of, 195 
pregnancy, secondary, 192 
uterus and foetus in, 192 
Abdomino-anterior positions, turning in, 

491 
Abortion and premature labor, 255 
artificial, 207 
causes of, 256 

importance and frequency of, 255 
most common in multipara?, 255 
production of, in extreme deformity, 

419 
spurious, 167 

subsequent management of, 267 
symptoms of, 260 
treatment of, 261 
tubal, 184 
Abscess of mammae. See Mammary ab- 
scess, 
pelvic. See Cellulitis. 
Accidental hemorrhage. See Hemorrhage. 
A. C. E. mixture in labor, 314 

in obstetric operations, 535 
Acute yellow atrophy of liver in preg 
• nancy, 230 
Adhesions, placental, 438 
After-pains, 564 
in labor, 280 
treatment of, 566 
Ala vespertilionis, 70 
Albuminuria in pregnancy, 214 
prognosis of, 214 
symptoms of, 214 
treatment of, 215 
Allantois, 106 

Alteration in shape of head from mould- 
ing, 294 
Alterations in tissues of uterus, 453 
Amnion. 104 
false, 104 
formation of, 105 
pathology of, 247 
structure of, 119 
true, 104 
Amniotic fluid, function of, 120 



Ampullar gestation, 180 
Anaemia in pregnancy, 211 
treatment of, 211 
Anaesthesia in labor, 312 
Anaesthetics, use of, in forceps delivery, 501 
Anasarca serosa, 659 
Anatomy of foetal head, 126 
Ante-partum hour-glass contraction, 374 
Anteversion of gravid uterus, 223 
Antiseptic injections, use of, 298 

precautions, 297 

in forceps delivery, 502 

rules for nurses, 557 
Apoplectic ovum, 257 
Apostoli's vaginal electrode, 190 
Arbor vita?, 61 
Area, embrvonic, 102 
Areola, 82 

appearance of, in pregnancy, 155 

secondary, 154 
■ Arm, dorsal displacement of, 348 

presentation of. See Shoulder pre- 
sentation. 

presentations, difficult cases of, 491 
Arrangement of foetal membranes and pla- 
centae, 176 
Arterial changes in villus stem of normal 

placenta at term, 122 
Arteries of uterus, 67 
Artificial abortion, production of, 207 

dilatation, 371 

of os uteri, 472 

human milk, 581 
Atropine in prolonged labor, 371 
Attitude of child in first position, 285 
Auscultatory signs of pregnancy, 160 
Aveling's method of transfusion of blood, 

548 
Axes of parturient canal, 44 
Axis- traction forceps, 498 



BACTERIOLOGY of genital tract, 57 
Bacillus, special vaginal, 57 
Ballottement, 159 
Bandl's ring, 143 

Bands and cicatrices in vagina, 375 
Barnes' bag for dilating the cervix, 472 
Basilyst, Simpson's, 523 
Bath, warm, in prolonged labor, .571 
Battledore placenta, 121, 247 
Bearing-down pains, 273 
Belladonna in prolonged labor, 371 
( 675 ) 



676 



INDEX. 



Bifid uterus, 69 

Bilobed uterus, gestation in, 182, 199 
Binder, application of, 310 
Births, frequency of multiple, 175 

plural, 383 
Bladder, irritability of, 219 
Blastoderm, 102 

bi-laminar, 102 

tri-laminar, 102 
Blastodermic vesicle, 102 

formation of, 101 
Blood, alteration in, after delivery, 558 

composition of, in pregnancy, 147 

defribination of, 550 

supply of uterus, 67 

transfusion of, 546 
Bony growth from sacrum, 406 
Braun's apparatus for replacing cord, 353 
Breech presentations. See Pelvic presen- 
tations. 
Brim, contracted, 408 
Brow presentations, 336 



pADUCA. See Decidua. 

\J Cesarean section, 378, 526 

causes of death after, 531 

requiring operation for, 523 
description of operation, 535 
history of, 526 
in America, 528 
in pelvic deformities, 414 
limits of obstruction, 529 
post-mortem, 530 
preparation of patient for, 534 
results' to child in, 528 
statistics of, 527 
subsequent management of, 537 
substitutes for, 539 
sutures in, 536 
use of anaesthetics in, 535 
Calculus, vesical, 379 
Caput succcdaneum, 285 

formation of, 294 
Carcinoma in pregnancy, 231 

of cervix uteri, 372 
Caidiac murmurs in pulmonary obstruc- 
tion, 650 
Caries of teeth in pregnancy, 209 
Carolina twins, 390 
Carunculse myrtiformes, 53 
Caul, 277 

Cavity of pelvis, 46 
Cephalic version, 478, 4S1 
Cephalotribe, 514 

Hicks', 516 
Cephalotripsy. See Craniotomy. 

and craniotomy, comparative merits 
of, 520 
Cellular layer, 113 

Cellulitis, pelvic. See Pelvic cellulitis. 
Cervix, changes in, during pregnancy, 143 
incision of, 373 
partial inversion of, 465 
rigidity of, a frequent cause of pro- 
tracted labor, 370 



Cervix, shortening of, 143 

softening of, 158 
Charnpetier de Kibes' dilator and intro- 
ducing forceps, 473 
Charlotte, Princess of Wales, death of, 367 
Child, newborn. See Infant. 

risks to, in forceps operations, 503 
Childbirth, management of women after, 
564 

mortality of, 557 
Chloral in labor, 312 
Chlorosis in pregnancy, 211 

treatment of, 211 

Chorea in pregnancy, 218 

prognosis of, 218 

treatment of, 218 

Chorio-decidual space, 110 

Chorion, 104 

frondosum, 112 

lseve, 112 

pathology of, 237 
Chorionic epithelium, 112 

villi, 110, 184 
Circular contraction, 374 
Circulation of foetus, 135 
Classification of pregnancy, 151 
Cleanliness, attention to, in labor, 298 
Clitoris, 51 
Coelom, 103 
Coccyx, 36 

ligaments of, 37 
Comparative results of various methods of 

treatment after ruplure of uterus, 459 
Complex presentations, 348 
Conception and generation, 97 

signs of fruitful, 151 
Constipation in pregnancy, 208 
Continued fevers in pregnancy, 227 
Contraction, hour-glass, 437 

of uterus after delivery, 560 

of vagina, 563 
Convulsions, puerperal. See Eclampsia. 
Corpora Wolffiana, 124 
Corpus luteum, 83 
false, 86 
true, 87 
Cough, spasmodic, in pregnancy, 209 
Cranioclast, Simpson's, 515 
Craniotomy, 511 

cases requiring, 516 

extraction of head in, 524 

forceps, 513, 515 

extraction by, 523 

formerly performed with unjustifiable 
frequency, 512 

method of perforating, 518 

religious objections to, 511 

use of crotchets in, 513 

use of perforators in, 512 
Cross-births, 340 
Crotchets, 513 
Crural phlebitis, 659, 661 
Curve, pelvic, 495 
Culbute, 129 
Cyst, contents of, 200 

opening of, by caustics, 199 



INDEX. 



G77 



Cystic disease of ovum, 23" 
Cvstocele, vaginal, 379 



[) 



EATH, apparent, of newborn. See 
Infant, 
sudden, from air in veins, 657 

during labor and puerperal state, 

656 
functional causes of, 657 
organic causes of, 656 
Decapitation, 524 
Decidua, 108 

formation of, 100 
hypertrophied, 235 
pathologv of, 234 
reflexa, 108 
serotina, 10S 
sub-chorionic, 117 
vera, 108 

imperfectly developed, 236 
Deciduoma malignum, 241 
Defective sanitation as a cause of puerperal 

disease, 617 
Delibrinated blood, 550, 555 
Deformity, figure-of-eight, 401 
from fractures, 406 
from old-standing hip-joint disease, 

406 
from ostemalacia, 403 
from tumors, 406 
of pelvis, 396, 454 
Delivery at term, 268 

hemorrhage after, 434 

before, 420 
methods of predicting probable date 

of, 169 
signs of recent, 172 
Denman's short forceps, 494 
Descent and, levelling movement in head 

presentations, 286 
Diabetes in pregnancy, 216 
Diacephalous monster, 390 
Diameters of foetal skull, 128 
Diet of nursing women, 574 
Digestive system, derangements of, 203 
Dilatation, artificial, 371 
Discus proligerous, 79, 99 
Diseases of pregnancy, 203 

affections of respiratory organs 

in, 209 
albuminuria in, 212 
anaemia and chlorosis in, 211 
caries of teeth in, 209 
chorea in, 218 
constipation in, 208 
diabetes in, 216 
diarrhoea in, 207 
dyspnea in, 210 
excessive vomiting in, 203 
hemorrhoids in 208 
leucorrhcea in, 220 
cedema of lower limbs in, 221 
palpitation in, 210 
paralysis in, 217 
pruritus in, 221 



Diseases of pregnancy, ptyalism in, 209 
spasmodic cough in, 209 
syncope in, 210 
tetanus in, 219 
toothache in, 209 
toxaemia in, 213 
transmitted through the mother, 249 
Disorders of nervous system, 216 

of urinary system, 219 
Displacements of gravid uterus, 222 
Distention of perineum, 303 
Division of labor into stages, 276 

of mechanical movements into stages, 
285 
Dorsal displacement of arm, 348 
Double monsters, 386 

division of, 388 
Dress of patient during pregnancy, 296 
Dropsical effusion, 393 
Ductus arteriosus, 136 

venosus, 136 
Duration of pregnancy, 168 
Duties on first visiting patient, 297 
Dyspnoea in pregnancy, 210 
Dystocia from excessive development of, 
foetus, 394 
from shortness of umbilical cord, 395 
treatment of, 394 



ECLAMPSIA, 585 
cause of death in, 588 
condition of patient between attacks 

of, 587 
confusion from defective nomencla- 
ture, 585 
etiology of, 585 
exciting causes of, 590 
MacDonalds's views of, 590 
obstetric management in, 593 
pathology of, 588 
premonitory symptoms of, 585 
relation of, to labor, 587 
results to mother and child in, 587 
toxsemic causes of, 590 
Traube and Eosenstein's theorv of, 

589 
treatment of, 590 
ursemic theory of, 589 
7 venesection in, 591 
Ecraseur, use of, as a substitute for crani- 
otomy, 515 
Ectoderm, primitive, 102 
Ectopic gestation. See Extra-uterine preg- 
nancy. 
Elbow presentations, 344 
Electricity as a means of destroying foetus, 

190 
Embolism. See Thrombosis 

puerperal, as a cause of pleuro-pneu- 
monia, 653 
physical signs of, 653 
treatment of, 654, 656 
Embryonic area, 102 
Kmbryotomy, 326, 524 
Endarteritis obliterans, 122 



678 



INDEX. 



Endometritis decidualis fungosa, 235 

Entoderm, primitive, 102 

Epilepsy in pregnancy, 229 

Eruptive fevers in pregnancy, 227 

Ether in labor, 314 

Evisceration, 525 

Evolution, spontaneous, 346 

Eye, diseases of, in pregnancy, 229 

Examination of child, 326 

Excision of cyst in abdominal gestation, 

197 
Exomphalos, 120 
Expressio foetus, 362 
Expression of placenta, 307 
Expulsion of child, 271 
Extension in head presentation, 2S8 

in face presentation, 330 
External rotation in head presentations, 

290 
Extra-uterine pregnancy, 1 80 

at term of secondary abdominal 
variety, 187 

cause of, 182 

classification of, 180 

condition of uterus in, 185 

history and progress of, 183 

laparotomy i,n, 189 

treatment of, 189 

after rupture, 191 

vaginal section in, 189 

varieties of, 182 



FACE presentations, 327 
descent in, 331 
diagnosis of, 328 
extension in, 330 
frequency of, 327 
flexion in, 332 
mechanism of, 329 
positions generally met with in, 

329 
prognosis of, 333 
rotation in, 331 
treatment of, 334 
Face-to-pubes delivery, causes of, 337 

treatment of, 338 
Fallopian tubes, 73 

structure of, 74 
False pains, 276, 299 

ovarian pregnancy, 185 
Faradic current, use of, in protracted 

labor, 362 
Faradization in destroying the vitality of 

foetus in extra-uterine pregnancy, 190 
Fatty degeneration of placenta, 244 
Fertilization, 97 
Fever, milk, 560 
Fibrinous degeneration, 123 
Fibroid tumors in pregnancy, 233 

of uterus, 375 
Figure of-eight deformity, 401 
Fillet, 510 

nature of instrument, 510 
objections to its use, 511 
Wilmot's, 510 



Flatness of sacrum, 402 
Fleshy mole, 258 
Flexion in face presentations, 332 
in head presentations, 286 
movement of, 286 
Flooders, 439 

Foetal cranium, section of, 416 
elements, 112 
head, anatomy of, 126 
heart, 136 

sounds of, in pregnancy, 162 
movements, 156 
skull, diameters of, 128 
structures, 122 

tumors obstructing delivery, 393 
Foetus, anatomy and physiology of, 124 
appearance of, at various stages of 

development, 124 
at term, 125 
changes after death of, 193 

in position of, during pregnancv, 
130 
circulation of, 135 
death of, 254 

diagnosis of, 254 
symptoms of, 254 
effect of gravity on, 132 
function of liver in, 137 
means of destroving vitality of, 1 90 
mobility of, 133 
mode of ascertaining position of, by 

palpation, 131 
mutilation of, 493 
nutrition of, 133 
operations involving destruction of, 

511 
pathology of, 248 
respiration of, 134 
size of, 175 
urine of, 138 

wounds and injuries of, 251 
Follicle, rupture of, 92 
Fontanelles, anterior and superior, 127 
Foot presentations. See Pelvic presenta- 
tions. 
Footling presentations, 315 
Foramen ovale, 135 
Forceps, 493 

action of, 499 

application of, in pelvic presentations, 
324 
within cervix, 374 
craniotomy, 513, 515 
Denman's short, 496 
delivery, method of introducing lower 
blade in, 503 
peculiar method of introducing 

blades, 507 
position of patient for, 502 
possible dangers of, 507 
risks of child in, 508 
traction in, 507 
description of, 493 
high, operations, 506 
in position, 505 
long, 496 



INDEX 



679 



Forceps, method of applying, 501 

-saw, 515 

short, 494 

Simpson's, 496 

axis-traction, 498 

Tarnier's, 49S 

use of, in modern practice, 493 

use of, in pelvic deformities, 414 

Zeigler's, 495 
Formation of a cyst around ovum, 192 

of placenta, 112 
Fossa navicularis, 54 
Fractures, deformities from, 406 
Funic souffle, 163 
Funis. See umbilical cord. 



GALACTOPHOROUS ducts, 81 
Galactorrhcea, 577 
Galbiati's sickle-shaped bistoury, 544 
Gastro-elytrotomy. See Laparo-elytrot- 

omv. 
Generation, internal organs of, 58 
Generative organs in female, 49 

division of, according to 
function, 49 
Genetic reaction, 107 
Germinal ventricle, 99 
Gestation. See Pregnancy, 
in a bilobed uturus, 199 
in one horn of a two-horned uterus, 201 
protraction of, 170 
tubal, 180 

diagnosis of, 188 
Graafian follicle, 77, 83 
formation of, 78 
human ovum from small, 99 
structure of, 79 
Gravid uterus, pressure by, 212 
Greenhalgh's pelvimeter, 412 



HEMATOMA of vulv?, 380 
Hematosalpinx, 184 
Hand-feeding, method of, 582, 
of infants, 5S0 
artificial human milk in, 581 
ass'si milk in, 580 
cow's) milk in, 581 
goat's milk in, 581 
Hand presentations, 344 
Hawksley's milk sterilizer, 583 
Haves' tube for intra-uterine injections, 

633 
Head presentation, attitude of child in 
second position, 291 
in third position, 291 
descent and levelling in, 286 
extension in, 288 
flexion in, 286 

external rotation of head in, 290 
mechanism of delivery in, 282, 

408 
mode of recognizing position in, 
282 



Head presentation, neck fixed under arch 
of pubes in, 289 
occiput at brim in, 294 
rotation in, 287 

of occiput forward, 292 
Hearson's thermostatic nurse, 477 
Heart disease in pregnancy, 228 
foetal, 136 
of infant, 137 
Hegar's sign of pregnancy, 139, 158 
Hemorrhage, accidental, 421, 431 
after delivery, 434 
before delivery, 420 
causes of, 423," 431 
constitutional, causes of, 449 
definition of, 431 
diagnosis of, 432 
differential diagnosis of, 433 
from laceration of maternal structures, 

448 
from separation of a normally situated 

placenta, 431 
pathology of, 431 
post-partum, 434 
prognosis of, 433 
secondary, ergot in, 451 
local causes of, 450 
post partum, 448 
treatment of, 451 
source of, 422 
svmptoms of. 432 
treatment of, 426, 433 
unavoidable, 421, 431 
Hemorrhoids in pregnancy, 208 
Hernial protrusion, 379 
Hicks' cephalotribe, 516 
Hip-baths, 202 

-joint disease, deformity from old- 
standing, 406 
Hour-glass contraction, 437 

treatment of, 443 
Hungarian twins, celebrated, 390 
Hydatidiform degeneration of chorion, 237 
Hydramnios. 247 
Hydrocephalus, intra-uterine, 391 

labor complicated by, 392 
Hydrorrhea gravidarum, 236 
Hypertrophied decidua, 235 



IMPREGNATION. 97 
1 Incision of cervix, 373 

of perineum, 304 
Incontinence of urine. 220 
Incubator, 477 

Induction of premature labor, 417, 468 
history of operation, 468 
objects of operation, 468 
Infant, apparent death of, 569 
treatment of, 569 
clothing of, 571 
evils of over-sucklim:, 572 
hand-feeding of, 580 
management of, 568, 574 

of, when food degrees. 447, 584 
period of weaning of. 575 



680 



INDEX. 



Infant, various kinds of food of, 584 

washing and dressing of, 571 
Infantile pelvis, 47 
Injection of defibrinated blood, 555 
Injuries of foetus, 251 
Insanity of lactation, 600 
of pregnancy, 595 
puerperal, 594 
causes of, 598 
classification of, 594 
form of, 596 

judicious nursing in, 604 
period of pregnancy at which it 

occurs, 596 
post-mortem signs of, 600 
prognosis of, 596, 599 
question of removal to an asy- 
lum, 604 
symptoms of, 601 
transient mania during delivery, 

596 
treatment of, 602 

during convalescence, 605 
Instrumental delivery in protracted labor, 

364 
Intermittent character of pains, 274 

contractions of uterus during preg 
nancy, 158 
Interstitial and false ovarian pregnancy, 
185^ 
.gestation, 180 
Inter-villous spaces, 117 
Intestine, scybalous masses in, 380 
Intraligamentous gestation, 180 
Intra-uterine amputation of both arms and 
legs, 252 
hydrocephalus, 391 
diagnosis of, 391 
.treatment of, 392 
Inversion, description of, 463 
differential diagnosis of, 463 
mechanism of, 464 
of cervix, commencement of, 465 

treatment of, 465 
of fundus, partial, 463 
of uterus, 462 

acute ;and chronic forms of, 462 
symptoms of, 463 
Irregular and spasmodic pains in pro- 
tracted labor, 358 
Irritabilitv of bladder, 219 



JAUNDICE, simple, in pregnancy, 230 
Judith and Helene, Hungarian twins, 
390 



KARYOK1NETIC chauges, 100 
Kiestein, 149 
Knee presentations, 315 
Knots of umbilical cord, 246 
Kyphotic pelves, 398, 405 



ABIA majora, 49 
J minora, 50 



Labor, acute and grinding pains in, 275 
administration of oxytocics in induc- 
ing, 471 
after-pains in, 280 
after-treatment in, 311 
anaesthesia in, 312 
attention to cleanliness in, 298 
causes of, 268 
chloral in, 312 

complicated by hydrocephalus, 392 
by ovarian tumor, 378 
with tumor, 375 
course of, 408 
difficult, depending on some unusual 

condition of foetus, 383 
division of, into stages, 276 
duration of, 280 

effectof pains on mother and foetus, 275 
effects of pelvic contractions on, 406 

prolongation of, 370 
ether in, 314 
expulsion of child in, 305 
first stage, or dilatation in, 277 
fixed epoch of, 269 
importance of proper management of 

third stage, 307 
management of natural, 295 
methods acting indirectly on uterus in 

inducing, 471 
missed, 200 # 
mode in which placenta is expelled 

in, 279 
obstructed by faulty condition of soft 

parts, 370 
phenomena of, 268 
premature, 255 

induction of, 468 
preparatory stage of, 276 

treatment in, 295 
protracted, causes of, 357 

dangers attending use of forceps 

in, 365 
effect of early interference on in- 
fantile mortality, 365 
evil effects of, 354 
instrumental delivery in, 364 
irregular and spasmodic pains in, 

358 
oxytocic remedies in, 360 
rigidity of cervix a frequent cause 

of, 370 
special value of uterine pressure 

in, 364 
symptoms of protraction in sec- 
ond stage of, 356 
treatment of, 359, 370, 373 
use of Faradic current in, 362 
second stage, or propulsion in, 278 
separation of membranes for inducing, 

474 
sources of pain during, 274 
stage of, in which delay occurs, 355 
state of uterus in protracted, 356 
third stage in, 279 

uterine contractions at commencement 
of, 272 



INDEX. 



681 



Labor, vaginal and uterine douches for in 
ducing, 474 

value of intermittent character (if 
pains in, 274 

various methods of inducing, 470 
Lacerations of vagina, 4C0 

of veins, 222 
Lactation, 568 

disorders of, 575 

insanity of, 600 

signs of successful, 574 
Laparo-elytrotomy, 530 

advantages over Cesarean section, 540 

history of, 540 

nature of operation, 540 
Laparotomy in extra uterine pregnancv, 
189, 191, 196 

mode of performing secondary, 19S 

puerperal, 459 
Leipothymia, 154, 210 
Leucorrhcea in pregnancy, 220 
Lever. See Vectis. 
Ligaments, broad, 70 

of uterus, 70 
Liquor amnii, 104 

deficiencv of, 243 

folliculi, 79 
Lithopa?dion, 194 
Liver, changes in, during pregnancy, 149 

function of, 137 
Lochia, 563 

occasional fetor of, 564 

variation in amount and duration of, 
563 
Locked twins, difficulties arising from, 

385 
Longings, 153 
Lumbo sacral joint, 36 
Lymphatics of uterus, 6S 



MALAEIAL puerperal fever, 632 
Malpresentation, frequency of, 408 
Mamma?, changes in, 154 
Mammary abscess, 577 

antiseptic treatment of, 579 
method of opening, 579 
treatment of, 578 
glands, 81 
Management of natural labor, 295 
Mania, puerperal. See Insanity. 
Maternal elements, 114 
impressions, 253 
structures, 123 
Maturation, 83 
Means of destroving the vitalitv of fcetus, 

190 
Measles in pregnancy, 227 
Measurements of pelvis, 41 
Mechanical advantage in turning, 415 
Mechanism by which inversion of uteru- 
is produced, 464 
•■if deliverv in head presentation, 2S2, 

408 
of shoulder presentations, 345 
Meconium, 13S 



Medullary folds 102 

groove, 102 
Membrana granulosa, 79 
Membranes, management of, in labor, 310 

puncture of, 427, 470 
Menstruation, 87 

cessation of, 95 

duration of, 89 

during pregnancy, 152 

influence of climate on, 87 
of race on, 87 

in monkeys and baboons, 92 

quantity of blood lost in, 89 

sources of blood in, 90 

theory of, 83, 92 
Mental peculiarities, 154 
Mento-posterior positions, treatment of, 

334 
Mesoblastic somites, 103 
Milk, artificial human, 5S1 

ass's, 581 

cow's, 581 

defective secretion of, 576 

excessive flow of, 577 

fever, 560 

goat's, 581 

secretion of, means of arresting, 575 

sterilization of, 5^3 

sterilizer, Hawksley's, 583 

transfusion of, 551 
Miscarriage. See Abortion. 
Missed labor, 200 

treatment of, 202 
Mode in which placenta is naturallv ex- 
pelled, 279 

of performing secondarv laparotomv, 
198 
Mole, fleshy, 258 

tubal, 184 

vesicular, 237 
Mollities ossium, 231 
Mons Veneris, 49 
Monsters, double, 3S6 
Morning sickness, 153 
Mortality of childbirth, 557 
Movements of pelvic joints, 38 
Mucous membrane of uterus. See Uterus. 
Midler, canal of, 70 

Multiparas, abortion most common in, 255 
Multiple pregnancy, 174 
diagnosis of, 177 
frequency of, 1 74 
Muriform body, 101 

Muscular.fibres, fatty transformation of, 561 
Mutilation of foetus, 493 
Myxoma chorii. See Chorion, 
degeneration of. 

fibrosum, 241 



VAKROWIXCr of transverse diameter, 

11 405 

Necessity of attending to first summons in 
labor, 296 

Nerves of uterus, distribution and arrange- 
ment of, 69 



G82 



INDEX. 



Nervous system, changes in, during preg- 
nancy, 148 
disorders of, 216 
function of, 138 
Neural canal, 102 

Newborn child, apparent death of, 569 
Nipple, 82 
Nipples, depressed, 576 

fissures and excoriations of, 576 
Notochord, 103 

Nurses, antiseptic rules for, 567 
Nursing. See Lactation. 

women, diet of, 574 
Nutrition of early ovum, 112 

of foetus, 133 
Nymphse. See Labia minora. 



OBLIQUELY contracted pelvis, 404 
Obturator membrane, 37 
Occipito-posterior .positions, difficult, 337 
Occiput at pelvic brim in head presenta- 
tions, 294 
at outlet of pelvis, 288 
in cavity of pelvis, 287 
rotation of, 292 
Occlusion of os, 374 
(Edema of lower limbs, 221 

of vulva, 380 
Oldham's vertebral hook, 513 
Orifice of vagina, 52 
Os innominatum, 33 

uteri, artificial dilatation of, 472 
villi of, 66 
Osteomalacia, 397 
Osteomalacic pelvis, 403 
Osteophytes, formation of, 143 
Ostium uterinum, 73 
Ovarian gestation, 181 

pregnancy. See Extra-uterine preg- 
nancy, 
interstitial and false, 185 
tumor in pregnancy, 232 

labor complicated by, 378 
Ovaries, 74 

removal of both, 92 
tumors of, 377 
Ovary, connections of, 74 
functions of, 83 
structure of, 75 
Ovariotomy, 378 
Ovula Nabothii, 67 
Ovulation and menstruation, 83 
Ovule, 79 

escape of, 84 
Ovum, apoplectic, 257 
blighted, 258 
cystic disease of, 237 

symptoms and prognosis of, 

239 
treatment of, 240 
nutrition of, 112 
pathology of, 234 
segmentation of, 100 
Oxytocic remedies in protracted labor, 
360 



PAINS, acute and grinding, 275 
after-, 566 
bearing-down, 273 
effect of, on mother and foetus, 275 
false, 299 
true, 299 
Palpitation in pregnancy, 210 
Pampiniform plexus, 68 
Paralysis in pregnancy, 217 
Parturient canal, axes of, 44 
Pathology of decidua and ovum, 234 
Pelvic articulations, 36 

cellulitis and peritonitis, 666 

channels through which pus may 

escape in, 671 
differential diagnosis of, 670 
early recognition of, 666 
etiology of, 667 
importance of distinguishing the 

true forms of disease, 667 
opening of abscess in, 673 
prognosis of, 672 
relative frequency of the two 

forms of disease, 669 
results of physical examination 

in/ 670 
seat of inflammation in, 668 
symptomatology of, 669 
symptoms of suppuration in, 671 
termination of, 671 
treatment of, 672 
variety of nomenclature, 666 
contractions on labor, effects of, 406 
curve, 495 

deformity, Csesarean section, 414 
causes of, 396 
diagnosis of, 410 
other causes of, 398 
osteomalacia as a cause of, 397 
rickets as a cause of, 397 
risk of child in, 407 

to mother in, 407 
spondylolisthesis as a cause of, 398 
treatment of, 413 
use of forceps in, 414 
joints, movements of, 38 
peritonitis, seat of inflammation in, 

669 
presentations, 315 
causes of, 315 
danger to children in, 316 
delivery of head in, 321 
diagnosis of, 206 
frequency of, 305 
mechanism of, treatment of, 318, 
322 
Pelvimeter, 411 

Greenhalgh's, 412 
Pelvis, adult, retaining its infantile tvpe, 
399 
anatomy of, 33 
axes of, 45 
brim of, 41 
cavity of, 46 
contracted, 409 
deformed by spondylolisthesis, 402 



INDEX. 



683 



Pelvis, deformities of, 396, 454 

development of, 46 

diameters of, 42 

differences in the two sexes, 40 

divisions into true and false, 34, 39 

female, 40 

funnel-shaped, 399 

in different races, 4S 

infantile, 47 

kyphotic, 405 

planes of, 43 

male, 41 

measurements of, 41 

obliquely contracted, 404 

occiput at outlet of, 288 
in cavity of, 287 

outlet of, 40 

osteomalacia, 403 

rickety, 401 

K >bert's, 406 

scolio-rhachitic, 400 

soft parts in connection with, 4S 
Perforators, craniotomy, 512 
Perineum, 54 

distention of, 303 

examination of, 311 

extreme rigidity of, 375 

incision of, 304 

relaxation of, 304 
Period of day at which labor occurs, 2S1 
Peripheral venous thrombosis, 659 
Peritonitis, pelvic. See Pelvic cellulitis. 

puerperal. See Septic disease. 
Pernicious ansemia in pregnancy, 211 
Phlegmasia dolens. See Thrombosis. 
Phenomena of labor, 268 
Phosphatic condition of urine, 220 
Phthisis in pregnancy, 228 
Placenta, adherent, signs of, 443 
treatment of, 443 

at term, 121 

battledore, 121, 247 

double, 244 

early, 112 

entire separation of, 429 

examination of, 310 

expression of, 307 

fatty degeneration of, 244 

formation of, 112 

functions of, 118 

growth of, 119 

membranacea. 243 

praevia, 420 

causes of, 420 
definition of, 420 
history of, 420 
prognosis of, 425 
symptoms of, 421 
turning in, 423, 490 

pathological changes in, 424 

pathology of, 242 

succenturia?, 243 

usual method of removing, 308 

uterine surface of, 121 

velamentous, 121 
Placental adhesions, 438 



Placental attachments, 116 
cotyledons, 121 
polypus, 266 
souffle, 163 
Placentitis, 123, 243 
Plasmodial layer, 113 
Pleural births, 383 

treatment in, 334 
Plugging of vagina, 428 
Pneumonia in pregnancv, 22S 
Polar globules, 100 
Porro-Csesarean operation, 537 
Porro's operation in missed labor, 202 

in rupture of uterus, 459 
Position in head presentations, 283 
of child at brim, 318 
of cranium in head presentation. See 

Head presentation, 
of patient during labor, 301 
Post-partum hemorrhage. See Hemor- 
rhage, 
causes of, 435 
curative treatment of, 441 
frequency of, 434 
injection of saline solutions in, 

442 
preventive treatment of, 440 
secondary, 448 

treatment of, 448 
Precipitate labor less common than linger- 
ing, 367 
Pregnancy, 139 

abdominal, 174, 192 

absence of menstruation a sign of, 

151 
albuminuria in, 211 
appearance of areola in, 155 
auscultatory signs of, 160 
carcinoma of, 231 
changes in cervix during, 143 
in liver during, 149 
in nervous system during, 148 
in urine during, 149 
in uterine parietes in, 142 
in uterus during, 139 
chorea in, 218 
classification of, 151 
composition of blood in, 147 
continued fevers in, 227 
diabetes in, 216 
differential diagnosis of, 165 
diseases coexisting with, 227 

of eye in, 229 
dress of patient during, 296 
duration of, 168 
epilepsy in, 229 
eruptive fevers in, 227 
extra-uterine, 180 

treatment of, 1S9 
fibroid tumors in, 233 
foetal heart-sounds in. 162 
general modifications in body pro- 
duced by, 146 
heart disease in, 223 
Ilegar's sign of, 139, 158 
increase in size of uterus during, 145 



684 



INDEX 



Pregnancy, insanity of, 59-5 
leucorrhoea in, 220 
measles in, 227 
modifications in certain viscera during, 

143 
multiple, 174 

diagnosis of, '177 
frequency of, 174 
oedema of lower limbs in, 221 
ovarian tumor in, 232 
paralysis in, 217 
pernicious anaemia in, 211 
phthisis in, 228 
pneumonia in, 228 
pruritus in, 221 
Kasch's sign of, 159 
scarlet fever in, 227 
shortening of cervix during, 143 
signs and symptoms of, 151 

of recent, 173 
simple jaundice in, 230 
size of uterus at various periods of, 

140 
spurious, 167 
syphilis in, 229 
tetanus in, 219 
toxaemia in, 213 
tubal, 183 

progress of, 186 
symptoms of rupture in, 1S6 
termination of, 186 
vaginal signs of, 158 
pulsation in, 159 
uterine fluctuation in, 159 
Pregnant uterus, relation of, to surround- 
ing parts, 140 
Premature labor, definition of, 255 

induction of, 417 
Presentations, brow, 336 
complex, 348 
face, 327 
shoulder, 340 

causes of, 342 
diagnosis of, 343 
frequency of, 343 
position of foetus in, 340 
prognosis of, 343 
treatment of, 347 
transverse, 340 ' 
Primitive, ectoderm, 102 
entoderm, 102 
groove, 102 
streak, 102 
Princess Charlotte of Wales, death of, 367 
Prolapse of cord, postural treatment of, 352 
of umbilical cord. See Umbilical cord 
causes of, 351 
diagnosis of, 351 
frequency of, 349 
prognosis of, 350 
treatment of, 351 
of uterus, 222 
Prolonged and precipitate labors, 354 
Pro-nucleus, female, 100 

male, 100 
Pruritus in pregnancy, 221 



Pseudocyesis. See Spurious pregnancy. 
Ptyalism in pregnancy, 209 
Puberty, changes occurring at, 88 
Puerperal arterial thrombosis and embol- 
ism, 654 
convulsions. See Eclampsia, 
fever. See Septic disease, 
insanity, 594 
true, 597 
laparotomies, 459 
malarial fever, 632 
mania. See Insanity, 
pleuro-pneumonia, 653 
septic disease, defective sanitation as 

a cause of, 617 
state, action of bowels in, 567 
and its management, 557 
attention to cleanliness in, 567 
coogulation in, 644 
diet and regimen in, 566 
importance of prolonged rest in, 

568 _ 
pulse in, 558 

secretions and excretions in, 559 
subsequent treatment of, 568 
temperature in, 559 
thrombosis and its results, 642 
venous thrombosis and embolism, 642 
Pulmonary obstruction, 650 

causes of death from, 651 
Puncture of membranes, 427, 470 



QUICKENING, 140, 157 
Quinine as an oxytocic, 361 



RASCH'S sign of pregnancy, 159 
Relaxation of perineum, 304 
Respiration, commencement of, 568 

of foetus, 134 
Respiratory organs, affections of, in preg- 
nancy, 209 
changes in, during pregnancy, 149 
Retention of urine, 219 

in utero of a blighted ovum, 266 
Retinitis in pregnancy, 230 
Retroversion of gravid uterus, 223 
causes of, 223 
diagnosis of, 224 
progress and termination of, 

224 
symptoms of, 224 
treatment of, 225 
Rickets, 397 

mode of production in, 400 
Rickety pelvis, 401 
Rigidity depending upon organic causes, 

372 
Ring, Bandl's, 143 
Robert's pelvis, 406 
Rosenmiiller, organ of, 70 
Rotation forward of chin, 331, 333 

in head presentations, 2S7 
Roussel's method of transfusion of blood, 
549 



INDEX. 



G85 



Rupture in tubal pregnancy, 1S6 
of uterus. (See Uterus. 

of membranes in version, 487 

of uterus, causes of, 453 

general symptoms of, 456 
Porro's operation in, 459 
premonitory symptoms of, 450 
prognosis of, 457 
statistics of, 461 
treatment of, 457 



O ACRO-ILIAC synchondrosis, 37 
O -sciatic ligaments, 37 
Sacrum, anatomy of, 35 
bony growth from, 406 
displacements of, 398 
flatness of, 402 
mechanical relations of, 35 
Saline solutions, injection of, 551 
Salivary glands, excessive secretion from, 

154 * 
Scarlet fever in pregnancy, 227 
Schafer's direction for immediate trans- 
fusion, 554 
method of transfusion of blood, 549 
Scolio-rhachitic pelvis, 400 
Scolioticpelvis, 398 
Scybalous masses in intestine, 380 
Secondary abdominal pregnancy, 192 

areola, 154 
Segmentation nucleus, 100 

of ovum, 100 
Semen, 97 
Septic disease, puerperal, 605 

administration of food and 

stimulants in, 636 
bacteria in, 623 
channels of diffusion in, 623 
through which septic 
matter may be ab- 
sorbed, 610,* 624 
conduct of practitioner in re- 
gard to, 607, 621 
cold water in treatment of, 

640 
conveyance of infection in 

atmosphere in, 616 
curetting the uterine cavity 

in, 635 
description of, 628 
difference of opinion as to, 

605 
division into autogenetic and 

heterogenetic forms, 611 
duration of, 630 
epidemics of, 60S 
history of, 606 

importance of antiseptic pre- 
cautions in, 621 
infection from ervsipelas in, 

614 
influence of zymotic disease 

in causing, 614 
internal antiseptic remedies 
in treatment of, 641 



Septic disease, purperal, laparotomy in, 641 
local changes in, 623 
medicinal treatment of, 63S 
micro-organisms in, 622 
mode in which the poison 
may be conveyed to pa- 
tients in, 620 
modern view of, 606 
mortality in Iving-in hos- 
pitals," 606 
nature of septic poison, 622 
pathological phenomena in. 

625 
pysemic forms of, 632 
prevention of, 621 
sewer-gas as a source of in- 
fection in, 616 
sources of auto-infection in, 
612 
of hetero-infection in, 
613 
theory of an essential zymo- 
tic fever, 609 
of its identity with sur- 
gical septicaemia, 609 
of its local origin, 608 
treatment of, 632 

by antistreptococcic se- 
rum, 637 
turpentine in treatment of r 

640 
Warburg s tincture in treat- 
ment of, 640 
use of evacuant remedies in 

treatment of, 640 
venesection in, 636 
Sex, discovery of, of fcetus during preg- 
nancy, 161 
of child, determining, 161, 175 
of foetus as influencing size of skull, 
129 
Shape of head, alteration in, from mould- 
ing, 294 
( Shows, 276 
j Siamese twins, 388 
j Signs and symptoms of pregnancy, 151 

of recent delivery, 172 
Simpson's axis-traction forceps, 498 
basilyst, 523 
cranioclast, 515 
forceps, 496 
Size of uterus at various periods of preg- 
nancy, 140 
Somatopleure, 103 
Spermatin, 97 
Spermatozoa, transit in, 9S 
Spermatozoon, 99 
Splanchnopleure, 103 
Spondylolisthesis, 298, 401 
Spondylolizema, 403 
Spantaneous evolution, 346 

version, 345 
Spurious abortion, 266 

pregnancv, 167 
Sterilized milk, 583 
Stroma, 113 



686 



INDEX. 



Subperitoneo-pelvic gestation, 180 
Superfoetation aud superfecundation, 177 
Symphyseotomy, 541 

history of, 541 

limits of operation, 542 
Symphysis pubis, 37 
Syncope in pregnancy, 210 
Syphilis in pregnancy, 229 

as a cause of abortion, 259 



rTAKNlER'S forceps, 498 

1 Tetanoid falciform constriction of 

uterus, 374 
Tetanus in pregnancy, 219 
Thermostatic nurse, Hearson's, 477 
Thorax, partial rotation of, 320 
Thrombi, changes occurring in, 663 
Thrombosis and embolism, distinction be- 
tween, 645 
conditions which favor, 643 
history of, 647 

peripheral, changes occurring in 
thrombi in, 663 . 
condition of affected limb in, 659 
detachment of emboli .in, 663 
history and pathology, 660 
period of commencement, 660 
progress of disease in, 660 
symptoms of, 659 
treatment of, 663 
venous, 659 
puerperal, causes of, 659 

phlegmasia dolens a consequence 

of, 646 
results of post-mortem examina- 
tions in, 645 
symptoms of, 655 
pulmonary, cardiac murmurs in, 650 
post-mortem appearances of clots 

in, 651 
treatment of, 652 
symptoms of pulmonary obstruction 
in, 647 
Thrombus, formation of, 381 
symptoms of, 381 
treatment of, 381 
Toothache in pregnancy, 209 
Toxaemia in pregnancy, 213 
Traction in forceps delivery, 507 

on groin, 326 
Transfusion, 448 

of blood, Aveling's method, 548 
cases suitabte for operation, 552 
dangers of operation, 552 
description of operation, 553 
history of, 546 
nature and object of, 547 
Roussel's method, 549 
Schafer's directions for immedi- 
ate, 544 
method, 549 
secondary effects of, 556 
statistical results of, 551 
of milk, 551 
Transit of spermatozoa, 98 



Transverse presentations, 349 
True pains, 277 

in labor, 299 
Trunk, presentation of. See Shoulder 

presentations. 
Tubal abortion, 184 
gestation, 180 

diagnosis of, 188 
mole, 1«4 
pregnancy, 183 

progress of, 186 
symptoms of, 186 
termination of, 186 
Tubo ovarian gestation, 180 
Tumors, deformity from, 406 
fibroid, 233 
ovarian, 232 
of ovaries, 377 
Tunica fibrosa, 79 

propria, 79 
Turning, 478 

anaesthesia in, 483 

antiseptic precautions in, 483 

by combined external and internal 

manipulations, 484 
choice of hand to be used in, 483 
history of operation, 478 
in abdomino-anterior positions, 491 
in placenta prsevia, 428, 490 
mechanical advantage in, 415 
period when operation should be per- 
formed, 483 
statistics and dangers of, 479 
Twins. See Plural births. 
Carolina, 390 
Hungarian, 390 
locked, 385 



UMBILICAL arteries, 136 
cord, 120 _ 

dystocia from shortness of, 395 
knots of, 121, 246 
pathology of, 246 
prolapse of, 349, 407 
vein, 136 
vessels, 106 
Urethra, 52 

Urinary system, disorders of, 219 
Urine, changes in, during pregnancy, 149 
incontinence of, 220 
of foetus, 138 

phosphatic condition of, 220 
retention of, 219 

after delivery, 565 
Uterine contractions at commencement of 
labor, 272 
promotion of, after birth of child, 
306 
fluctuation as a sign of pregnancy, 

159 
hydatids, 237 

mucous membrane, changes in, 562 
parietes, changes in, 142 
pressure, special value of, in pro- 
tracted labor, 364 



INDEX. 



687 



Uterine souffle, 163 

surface of placenta, 121 

vessels, changes in, 502 
Utero-gestation, table for calculating the 
period of, 170 

retention in, of a blighted ovum, 200 

-sacral ligaments, 72 
Uterus, 53 

alterations in tissues of, 453 

and fu?tus in abdominal pregnancv, 
192 

and appendages in an infant, 59 

anomalies of, 09 

arteries of, 07 

bifid, 09 

blood supply of, 67 

changes in, 139 

condition of, in extra-uterine preg- 
nancy, 185 

contraction of, after delivery, 560 

dimensions of, 60 

extreme distention of, 269 

fibroid tumors of, 375 

gestation in bilobed, 199 

gravid, anteversion of, 223 
displacements of, 222 
pressure by, 212 
retroversion of, 223 

inversion of, 462 

irregular contraction of, 437 

ligaments of, 70 

lining membrane of, 63 
anatomy of, 63 

lymphatics of, 6$ 

mucous membrane of, 64 

muscular fibres of, 62 

nerves of, 69 

prolapse of, 222 

rupture of, 452 

size of, at various periods of preg- 
nancy, 141 

state of, in protracted labor, 356 

structures composing, 61 

tetanoid falciform construction of, 374 

transverse section of, 59 

value of anaesthesia in relaxing, 492 

villi of, 60 



YAGIXA, 55 
bands and cicatrices in, 375 
contraction of, 563 
lacerations of, 460 
orifice of, 52 
plugging of, 423 
right half of virgin, 55 
structure of, 55 
Vaginal and uterine douches for inducing 
labor, 474 
dangers of, 475 
cvstocele, 379 



Vaginal examination, 298 

mode of conducting, 299 

laceration, treatment of, 462 

pulsation, 159 

section in extra-uterine pregnancv, 
189 

signs of pregnancy, 158 
Value of anaesthesia in relaxing uterus, 

492 
Vectis, 509 

action of, 509 

cases in which it is applicable, 509 
Veins, laceration of, 222 
Velamentous placenta, 121 
Venous transfusion, direct, 554 
Ventral stalk, 106 
Vernix caseosa, 126 
Version, bi-polar, 484 

by external manipulation, 4S0 

cephalic, 478, 481 

method of performing, 482 

completion of, 490 

rupture of membranes in, 487 

spontaneous, 345 

statistics of operation, 479 
Vesical calculus, 379 
Vesico-uterine ligaments, 72 
Vesicular mole, 237 
Vestibular band, 51 
Vestibule, 51 

Villi of os uteri stripped of epithelium, 
66 

of uterus, 66 
Viscera, modifications of certain, 143 
Vitality of foetus, means of destroying, 190 
Vomiting, excessive, in pregnancy, 203 
Vulvo, hematoma of, 380 

oedema of, 380 

vascular supply of, 54 
Vulvo-vaginal glands, 53 



WEANING, period of, 575 
Wet-nurse, selection of, 573 
Wharton's jell v, 240 
White infarcts, 123 

leg, 059 
Wilmot's fillet, 510 
Wolffian bodies, 09 
Wounds of foetus, 251. 



ELK, SO, 99 



ZEIGLER'S forceps, 495 
Zona granulosa, 99 
radiata, 79, 99 
Zymotic disease affecting the foetus, 249 
as a cause of septicaemia, 014 



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